To start our conversation today, I was hoping you could provide us with some context around the RUSH Cancer Center's use of physical medicine and rehabilitation in therapy for cancer patients.
People often ask me what cancer rehab it or what a physiatrist is. Cancer rehab is an umbrella term that's covering myself as a physiatrist, physical therapist, occupational therapist, speech therapist, but there's often confusion between myself as a physician and a physical therapist. By no means am I a physical therapist and I don't have their expertise in physical therapy, but we work very closely, so I speak the same language as the therapists. I'll stay in touch with them often and, even if I send a patient to therapy or another provider sends them to therapy, they may reach out to me and say this patient has a barrier going on or they have knee pain. Do you think you could see them in clinic? I think it's really important for myself to keep getting the word out about cancer rehabilitation and showing people what it is, including our own physical medicine and rehab residents who may not know that cancer rehabilitation is a specialty or might not know if they're interested in it.
To give some history around PM&R and cancer: historically, the outcome cancer providers are most focused on is survival, and rightfully so. Our job as physiatrists is to really optimize the quality of that survivorship for patients. My role is to maintain or restore function, minimize symptom burden, maximize independence, and ultimately improve quality of life for cancer survivors. Cancer rehab is a large multidisciplinary team and includes myself, physical therapists, occupational therapists, speech language pathologists, dietitians and psychologists as well. I often tell patients I'm their quarterback for function; I can help identify which of these services the patient may need and coordinate them based on their impairments, as obviously I'm not going to send every single patient to every service as well.
The number of dedicated cancer physiatrists across the country is growing right now, but we still need more. Patients can most often find a dedicated cancer physiatrist at a large academic institution or comprehensive cancer center, but not all patients have access to those. As treatment continues to evolve, the number of cancer survivors will continue to grow. According to the most recent figures, there was about 18 million survivors in 2022, and about two-thirds of these survivors are 65 years of age or older. It's a growing population of older Americans, and they're more at risk for developing cancer or treatment-related impairments. But they’re already coming in with some nonrelated impairments to cancer, so those numbers are going to keep growing. And, unfortunately, in that same report from the American Cancer Society, it was estimated that only 1 to 2 percent of survivors receive rehab. I'm very happy that I'm back at RUSH now and we're building our own cancer rehabilitation program.
From a physiatry standpoint, the incorporation of physical medicine and rehabilitation within cancer care was first described in the literature between the 1970s and 1990s. Can you talk about how physiatry has been more widely incorporated within hospitals since then?
Its relevance and prevalence has really grown since that time, and it also kind of grew once dedicated fellowships began, so the first dedicated fellowship was actually at MD Anderson in Houston where I trained, and that had started in 2007. Now we're really seeing a big focus on survivorship and that quality of survivorship, so really there's a bigger demand, so we have to meet that demand with more dedicated trainees as well.
With your work at the RUSH Cancer Center, can you provide a breakdown on the type of cancers that you help patients with? Are there ones that are more common that you treat or are there ones you're unable to help patients with, or can you give us some context around that?
That's a great question. There isn't really an all-inclusive list of types of cancers I'll see. I'll see some more often than others such as breast cancer and head and neck cancer, but I also see a wide variety of solid tumor and liquid tumor cancer populations. Certain populations may suffer from cancer-specific or treatment-specific impairments. For example, in the head and neck cancer population, you'll often see radiation fibrosis in the neck with things like cervical dystonia, trismus, which is difficulty opening the jaw, or in the breast cancer population, things like aromatase inhibitor syndrome or postmastectomy pain.
When I see a patient, I'm more so looking at their impairments. These impairments are most often physical, things like deconditioning, fatigue, neuropathy, pain, mobility and activity of daily living impairments, but the impairments can also be cognitive or psychological. There isn't a certain cancer population that I won't see. And when I first meet a patient, it's really important for me to understand their previous cancer treatment history, including things like chemotherapy, surgery and radiation. This can help me narrow down the culprit for their symptoms.
For example, in a breast cancer patient, knowing if they received chemo, what type of surgery and when they received radiation can help me identify the cause of their pain, their neuropathy or even the risk of them developing arm swelling like lymphedema. And then discussing the patient's goals, whether it be to throw the ball with their grandchild, return to work or just get back to a hobby they previously enjoyed helps me and the patient decide on a plan for them together. Rehab is most often restorative or bringing someone back to as close as we can to their prior level of function before diagnosis. This is what I see most often in the outpatient setting. But I also do see patients in the hospital during inpatient consults, so obviously these patients are acutely sick and admitted to the hospital so they're at risk to lose about 1 percent of muscle mass per day when they're critically ill. We really want to minimize their loss of muscle, their loss of function and address any current symptoms they have.
I'll evaluate them for the most appropriate level of post-acute rehab, something like acute rehabilitation, which we have at RUSH, which is really three hours of therapy five days per week. But there are times where rehab will be more supportive or palliative based on the patient's disease, their treatment options and their prognosis. It's important for me to really stay in touch and communicate with their cancer team.
I know you mentioned before about the stage of the cancer or when they received treatment can affect the way that you approach their rehabilitative care. I'm curious if you could talk a little bit more about those specific means that you'll help patients and in what ways does the type of treatment impact how you're able to help them or I know you talked about their goals, too, for quality of life. Can you maybe expand a little bit upon that work into some more detail?
Really just being on the same page as the patient, seeing if they understand where they are at in their cancer journey and then also in the hospital sometimes discussing with the primary team about where they are in that workup. But after understanding a patient's impairments, goals and kind of where they're at in their journey and seeing what paths current and future treatments there are, I have a slew of tools in my toolbox to help them out. Depending on the stage of their cancer, this can include things like lifestyle changes, exercise management and addressing exercise barriers, nutrition management, referral to therapies as I previously mentioned, topical or oral medications, and then certain types of injections, such as trigger point injections for myofascial pain, peripheral joint injections and other musculoskeletal injections, including nerve blocks and then botulinum toxin injections for a variety of diagnoses as well, including spasticity, migraines, dystonia and trismus in the head and neck population, postmastectomy pain and chest wall spasms in the breast cancer population.
And then, additionally, in certain populations we now have a growing role for preventative rehab, or prehabilitation, to really address preventing these impairments. When patients are planned to undergo a certain intervention like surgery or a stem cell transplant, we may have a window where they will be receiving chemo and we can really optimize their function prior to this intervention and ultimately the goal is to decrease their length of stay in the hospital, minimize their treatment-related impairments, reduce mortality and future readmissions. The better shape someone walks into the hospital, it’s likely the better shape they'll walk out.
With physical medicine and rehabilitation or what you talked about with the prehabilitation, if that is challenging for patients to deal with so many different providers and you have another provider coming in working on getting them ready and kind of in the best shape for treatment, is there a level of maybe seeing too many providers overload? That's also sort of involved in the process and working with these patients before they start their cancer treatment.
Yeah, that's, that's a fantastic point. And that's always on my mind as well, especially as we're developing our own prehabilitation programs here at RUSH. My goal with a prehabilitation program is to really provide a patient a home exercise program and getting them to do more aerobic activity and resistance training whether that be with body weight or resistance bands. Certain times we will identify an impairment or a barrier that may require formal physical or occupational therapy, but really our goal is to have an appointment with myself and then a physical therapist that provides baseline functional measures, and from my end I'm really screening for any barriers and seeing if there's any symptoms that are getting in the way and then really setting them off with a plan to be successful at home prior to their intervention and then following up with them afterwards.
I have the luxury of still being able to see them when they're in the hospital during my consults as well. Even for my own clinic too, I know patients have a ton of appointments. I'm often trying to line up their appointments on days they're already going to be here or even utilizing virtual care now.
Nutrition and exercise are really important for everybody, but in particular they're incredibly important for cancer patients. Can you tell us why? Why is it so important for cancer patients to focus on getting good nutrition?
We're kind of at the point where we have plenty of literature showing the importance of exercise and nutrition and not only in prevention and survival, but also symptom burden and how we can improve that such as fatigue, mood, bone health, physical function and, ultimately, quality of life. Now we're looking at how do we implement this. For me, as I mentioned, my role's not only providing the exercise recommendations to help patients be more successful during treatments or even be more eligible for treatments if they're in better shape, but identifying barriers they may have that are precluding them from exercising safely. That could be something like as simple as osteoarthritis in their knee or balance issues due to neuropathy that's stopping them from being a little bit more active.
And then with nutrition and specifically protein intake, it's been shown that's very important for patients during treatment to reduce the risk of malnutrition, sarcopenia, cachexia and muscle loss. There are several guidelines that recommend an increased amount of protein intake compared to the general population. I'll often screen patients for these things, discuss it with them and I also refer patients to a dietitian if they already haven't met with one or are interested in doing so.
Are there additional nutrition guidelines in addition to protein that are important for cancer patients to keep in mind as they're going through treatment to help them with some of that symptom management?
It really comes down to monitoring their weight and kind of seeing where they are in terms of their caloric intake and any barriers they might have to their nutritional intake as well. At times there aren't specific guidelines on the amount of nutrients they specifically need. My big focus is trying to get them to just eat more because sometimes we'll be seeing patients that just aren't getting any calories and finding strategies to include more calorically dense foods can be very beneficial.
A similar question or along that same line are in what ways are cancer patients who need physical medicine and rehabilitation different than those of a typical PM&R patient?
Our typical PM&R patients—if you want to think about a post-stroke patient—have undergone a static event and they usually have recovery and then they eventually plateau. Compared to a cancer patient, they're a little bit more dynamic in nature, so they can have these small increases in function or these little victories and then you see this decline again and that can change based on their disease progression, further treatments or recurrence. It's more of a roller coaster ride compared to our classic PM&R patients.
As I mentioned earlier there are cancer and treatment-specific impairments that I need to be aware of as well. Being aware of past, present and future treatments is key for me and, at times communicating with their team, such as the medical oncologist or surgical oncologist, is important before proceeding with my treatment plan to make sure it's okay from their standpoint.
Given all the ways that you can improve a cancer patient's treatment journey, are there any sort of evaluative measures that you use to know that the care that you're providing is effective for that patient?
For me, it really comes down to patient feedback. I use a patient-reported outcome scale with all new patient visits and then follow-ups and it's the promise cancer function, brief 3D profile. So this really gives me feedback on the patient's physical function, their fatigue and social participation. And then in my clinic as well, we use a dynamometer to measure their grip strength and we have them complete a 30-second sit-to-stand. This helps me see where they are functionally and hopefully we can see those measures improve over time.
As we pilot some of these prehab programs, we'll be collecting additional functional measures. These will be collected at the initial evaluation and then at follow-up, so this can include six-minute walk tests, evaluating their gait speed, sit to stand, grip strength and then that promise questionnaire I mentioned.
When it comes to a disease-specific group, such as the breast cancer patients, we'll likely include some specific measurements for them as well such as range of motion and strength at the shoulder, because it's very common for them to have shoulder and scapulothoracic dysfunction after their treatment. There is some overlap between all the populations, but we do have to look at specifics for certain ones.
You said early in the conversation about how not every hospital's going to have this integration of PM&R with cancer care. I'm just wondering for referring providers who may not be familiar with this offering, what would you want them to know outside of what we've talked about in terms of maybe symptoms that their patients have that they're treating?
I think my goal ultimately is really looking at patient survivorship. I think it's great that survivorship numbers are improving. People are living longer after cancer, but your survivorship should be quality too, so you shouldn’t be living in misery. You shouldn’t be suffering. Knowing that someone like myself exists can really be very beneficial for patients and that's ultimately what we're here for is to help patients.
Is there a point when it's been too long when physical medicine and rehabilitation maybe won't be as effective as if they were closer to their treatment time or can those patients still be helped by PM&R care later on in their survivorship journey?
They can be helped. It's just a lot more beneficial to see them earlier. if they have a certain symptom or impairment, it doesn't just chronically worsen over time. The earlier we can get them in, the earlier we can address it and especially when it comes to things like function. If we can prevent muscle loss and strength loss, it's a large difference of working from a beginning point than waiting until they're using either a walker or using a wheelchair for distances and then trying to build them back up from there.