The research team, led by Luna Gauchez of the Rehabilitation Research Group at Vrije Universiteit Brussel together with colleagues from the End-of-Life Care Research Group and UZ Brussels, conducted thirty face-to-face, semi-structured interviews across hospital, nursing home, and primary care settings in Brussels and Flanders. The sample was deliberately balanced: ten adults with advanced cancer, ten physicians including oncologists and general practitioners, and ten physical therapists. Using purposive and snowball sampling, the researchers captured perspectives from every link in the referral chain, from the person who would receive the therapy, to the clinician who would order it, to the professional who would deliver it. Interviews were analyzed inductively with the Framework Method, a structured qualitative technique that allows researchers to systematically chart themes across different participant groups while preserving the nuances of individual accounts.

The study’s central finding is deceptively simple: engagement with physical therapy in advanced cancer is shaped by a combination of behavioral factors operating at both the individual and environmental levels, and when these factors fail to align across the three groups, the entire system stalls. Patients may want to move but not know that therapy is available or reimbursed. Physicians may believe in its value but lack knowledge of local providers or referral procedures. Physical therapists may be willing to treat but feel unprepared for the complexities of oncology. Each barrier is small on its own; together they form a wall.

For patients, the decision to engage in physical therapy hinged on several intertwined factors. Symptoms themselves, particularly fatigue, pain, and weakness, could either motivate a search for help or make the prospect of exercise feel overwhelming. Perceived benefits played a decisive role: patients who understood that therapy could improve function and reduce discomfort were far more likely to participate than those who saw it as irrelevant to a life-limiting illness. Coping style mattered as well, with some patients embracing active management of their condition while others preferred to conserve energy or focus elsewhere. Social support from family and friends emerged as a facilitator, and so did practical awareness, including whether patients knew what physical therapists actually do in cancer care and whether the service was covered by health insurance. The researchers found that many patients simply had no clear picture of what physical therapy could offer them at this stage of illness.

Physicians, meanwhile, stood at a different bottleneck. Their referral decisions depended on their knowledge of the indications for physical therapy in advanced cancer, their familiarity with local providers, their understanding of referral procedures, and their expectations about whether therapy would actually produce meaningful outcomes. A physician who did not know a competent oncology-trained physical therapist nearby, or who doubted that a patient with limited life expectancy would benefit, was unlikely to make the referral, even when the patient might have gained substantially from it. This finding echoes earlier international work, including studies documenting the reluctance of palliative care clinicians to refer patients for rehabilitation and analyses showing that underutilization of rehabilitation services among people with advanced cancer is a persistent, well-documented problem in oncology systems worldwide.

On the supply side, the physical therapists interviewed described how their delivery of care was shaped by their oncology-specific knowledge, their confidence in working with patients facing serious illness, their attitudes toward palliative populations, and the organizational support available to them. Therapists without specialized training in cancer care reported uncertainty about safe exercise parameters, symptom management, and how to adapt treatment as the disease progressed. Those embedded in supportive institutional environments, with time, mentorship, and interdisciplinary collaboration, described far greater capacity to serve this population. The study thus identifies workforce competence and organizational structure as critical environmental levers, not merely individual willingness.

The theoretical framing of the study adds scientific weight to these observations. The researchers drew on established behavioral science, including the theory of planned behavior and the health belief model, both of which posit that behavior, whether a patient’s participation or a physician’s referral, is driven by attitudes, perceived norms, perceived control, and expectations of benefit. Earlier work by the same Belgian group had systematically reviewed the use of behavioral theories in end-of-life care research and argued that they could illuminate why health-promoting behaviors are so rarely adopted in palliative contexts. The new study applies that lens empirically, and the results validate the approach: the barriers and facilitators identified map cleanly onto knowledge, motivation, and environmental constraints, the classic domains of behavioral models.

What makes the study particularly compelling is its demonstration of misalignment across the three groups. A patient might be motivated but never referred because the physician lacks procedural knowledge. A physician might refer enthusiastically but the patient declines because they misunderstand the purpose of therapy. A physical therapist might be skilled and available but never reached because no one in the chain knows they exist. Integration, the authors conclude, is not blocked at any single point but by the failure of information, expectations, and communication to flow across the entire pathway. This systems-level insight reframes the problem: fixing one link, say, educating patients about reimbursement, will not suffice if physicians remain unaware of indications or therapists remain undertrained in oncology.

The practical implications are significant for cancer care systems far beyond Belgium. The authors call for multilevel strategies targeting knowledge, roles, communication, and system structures. Concretely, that could mean embedding physical therapists within oncology and palliative care teams so that referral becomes a routine conversation rather than an exceptional one; educating physicians about the evidence base for rehabilitation in advanced disease; clarifying reimbursement pathways so that cost is not a hidden barrier; and expanding oncology-specific training in physical therapy curricula so that graduates feel confident treating patients with complex, progressive illness. Prior systematic reviews by members of the same team have already documented which physiotherapy modalities are recommended for palliative oncology patients and their effects on patient-reported outcomes, giving clinicians an evidence base to act on once the referral barrier is lowered.

The study also carries a human message that resonates well beyond the clinic. Qualitative work with patients across the palliative literature consistently finds that movement, achievement, and purpose matter profoundly to people living with life-limiting illness, and that exercise-based interventions can deliver a sense of agency when so much else feels out of control. The Belgian findings suggest that many patients are being denied that opportunity not because therapy cannot help them, but because the system has not made it visible, accessible, and trusted. As populations age and more people live for years with advanced cancer, closing this gap between what rehabilitation science can offer and what patients actually receive may become one of the defining challenges of supportive cancer care. This study provides the roadmap: align the knowledge, expectations, and communication of the people who give, receive, and refer, and physical therapy may finally take its place as a standard component of advanced cancer care rather than an underused afterthought.

Subject of Research: Barriers and facilitators to integrating physical therapy into advanced cancer care

Article Title: Perspectives on physical therapy in advanced cancer care from those who give, receive, and refer: a qualitative interview study

Article References: Gauchez, L., Beernaert, K., Decoster, L., Deliens, T., Van Ginderdeuren, F., Adriaenssens, N., & Scherrens, A.-L. (2026). Perspectives on physical therapy in advanced cancer care from those who give, receive, and refer: a qualitative interview study. Supportive Care in Cancer, 34(11), Article 1110. https://doi.org/10.1007/s00520-026-11352-z

Image Credits: AI Generated

DOI: 10.1007/s00520-026-11352-z

Keywords: physical therapy, advanced cancer, palliative care, qualitative research, referral barriers, quality of life, oncology rehabilitation, patient engagement, physician referral, behavioral factors, supportive care, Belgium