So, hi everybody. I'm interrupting for a second. I'm Dr. Diana Cardenas. I'm a professor and chair emeritus at the University of Miami, but my real role and mission now is I'm president of the Foundation for Physical Medicine and Rehab. And one of the things of the new initiatives that we're working on, and I hope you've all heard about, is cancer rehab. So, we're trying to create a fund on cancer rehab research because that's what really we need for the field to show everybody we know what we're doing and make things better for our patients who have cancer. So, that's all I wanted to say to please donate. If you want more information, you've probably been getting information from us about online to click and donate and whatnot, but if you have any questions, please contact the Executive Director at P. Anderson at FoundationforPMNR.org. Thank you very much. Hi. Welcome all. Thank you for joining us. My name is Christina Klein-Caros. I'm coming to you from Vanderbilt and I'll be getting us started with our presentation, A Comprehensive Breast Cancer Prehabilitation Program, Bridging the Gap Between Rehabilitation and Supportive Oncology. For our group, I'll be getting us started with an emphasis on shoulder function, upper mobility, and general exercise counseling. Dr. Power will then lead us in an overview of lymphedema and Dr. Martone will finish our presentation overview of complementary and alternative medicine. All right. I have no personal disclosures. I did just want to disclose I will briefly highlight a few patient educational videos that we created and those were created with funding from the Cancer Charities Fund from the Rockefeller Philanthropic Advisors. All right. So, for my presentation, my aims are that at the end of this presentation, you will be able to describe the benefits and the role of prehabilitation for individuals with breast cancer. You're also going to be able to counsel patients on aerobic and resistance exercise training. To get us started, let's just start by defining cancer rehab. I've highlighted here one published definition and it really highlights the fact that it is medical care that should be integrated throughout the oncology care continuum. So, that's going to be inclusive of that prehabilitation timeline. Delivered by trained rehabilitation professionals, so you all in the audience, to really work with patients to maintain, restore their function, reduce symptom burden, maximize independence, and improve quality of life. So, as we're thinking of the comprehensive nature of this definition, it really highlights the opportunities for prehabilitation to be incorporated and that's where we'll go next. So, thinking about prehab in oncology. Oftentimes, when patients receive their new cancer diagnosis, they may not be in the optimal health at that time. This is really an opportunity for us to intervene. Thinking about that timeline, at the time of their cancer diagnosis, you know, there may be several weeks to several months before initiating treatment or several weeks to several months of neoadjuvant treatment before a planned surgery or radiation. That is our opportunity in our timeline to make, intervene, and have these opportunities for improvements for our patients. This is an emerging strategy to help buffer against that anticipated decline. And so, as you can see in the second table, as we're getting that improvement in prehab, although we are still seeing that similar decline, the nature of that functional decline is not as significant as if they had not had any prehabilitation. All right. So, thinking about some breast cancer statistics and why prehabilitation would be important for this patient population in particular. Breast cancer is the most common cancer among women and has overall high rates of survival. So, women are going to be living for Unfortunately, a more sobering statistic is that 87% of women with breast cancer are gonna report some upper extremity symptom that is even higher when there is metastatic involvement. And unfortunately, in this study, despite 92% some of the common upper body pains and functional disorders you'll see highlighted on this slide. I'm not going to go through them all, but you can see there is a plethora of potential impairments that people may experience both in the acute time frame as well as long term. Keeping this slide in mind and the numerous functional impairments, I want you to think about that in relationship to our ICF framework. So our International Classification of Function. function, and by intervening with prehabilitation, we can then improve their quality of life. To kick us off, I wanted to start by highlighting and has confirmed involvement. treatment plan includes neoadjuvant chemotherapy. Then, we're thinking about her. specifically for her with So that's going to predispose her further to rotator cuff micro. considerations are related to radiation. So first for us in the immediate the side, contralateral to the So, our goals for rehab, these are going to be general goals both for in that prehab time frame, also our rehab goals for her afterwards in the long-term period. We want to restore her joint mobility. doing this. What is the evidence showing us in terms of the benefit? So with prehab and intervening early... prehab program. We're also going to talk about general exercise conditioning. We're going to target major muscle groups with resistance. So, first to start off with, I want to highlight that when I think of prehab, I don't want us to think about it in an isolated time frame of we've done our prehab, they've gone to surgery, and now we've washed our hands and we're done. Prehab instead should be part of the I'm going to highlight here. Campbell at all really highlighting this prospective model with what they're terming the preoperative or for us translating With this, it has still incorporating... and that potential for this interdisciplinary collaboration within our survivorship model. All right. So how do we translate what's been shown in the literature in terms of what we've learned in the literature in terms of what we've learned in terms of what we've learned in terms of So when we were implementing A few important information to know about R&D. Lastly, I will transition to our general exercise counseling. What I've highlighted here... evidence of resistance exercise helping with bone health and aerobic activity helping with sleep. However, as I start to talk about this with patients, although for some of you thinking And just to point out, these exercise recommendations are. that there is benefit specific. I have overly simplified it. Right, so in summary, prehabilitation improves shoulder range of motion, upper extremity functional recovery, and reduced post-operative pain, conditionally physical activity, and Hi, I'm Kat Power, I'm going to be... Oh, no worries! I always assume it's me. So, no disclosures, I still have... Uh, so, to reiterate... So, this was a study by Nicole Stout, who, you know, maybe somebody's heard of it. And it was looking at— But a huge difference for a particular... It also means as a whole so looking at a larger group of So, uh... In this setting, in the prehab, I. this day, but people read and And I just felt like it helped give So, the third value that we have, program building, so... So what does that mean? So in working with our colleagues. And it's just a way Today, as we've talked about before, we have... and say, oh yeah, that doctor, they really helped me with blank, blank, and blank, and that lymphedema that we talked about. So screening. Is it necessary? Yes. The position statement that has yet to be updated, but as of 2011. and 40%, but who else is... So, biopedance analysis... It's it generates what's called it varies. So what are some advantages of using this? It's fairly reliable, diagnostically accurate, studies have shown that it's... negative. There aren't that many vendors or suppliers. It can be pretty costly to have this. It's not for everyone. The older versions of bioimpedance were handheld. You did it in the office and they could not look at patients at risk bilaterally. The newer version has that advantage and it has some other advantages as well. So their protocol is that the... If patients thus have a positive test, they recommend So, this was one. Infrared optoelectronic geometry, so it's also a reliable tool. It's positive, it's reliable, valid, efficient. It's also volumetric measurements. Tried-and-true sequential circumferal circumferential cool tape measurements. It also allows for limb Positive, it's very cheap. I mean, my tape measure costs like 99 cents from Amazon. It's pretty reliable. It's valid. It's very easy to teach. I'm currently at Northwell Health, happily employed. And so we are going to talk about, I'm gonna try to bring this together now. The goal of this talk was to talk about a comprehensive prehabilitation program. And I think a lot of people in this room understand the importance of prehabilitation, right? So we're teaching our patients those chest wall exercises, maintaining that shoulder mobility to maximize function before surgery. We're doing the lymphedema surveillance. We're getting those baseline measurements. I think we all get that and can grasp onto that concept. But what else can we be providing in these prehabilitation visits? And why is it important that we're providing more things? The answer is that these patients are hit with the sledgehammer of a diagnosis, right? They're hit with this diagnosis, and they're told you have to go see these four to five people and right away, we have to get these appointments in. How can we justify having another appointment for these patients right at the time of their diagnosis? And the way that we can do that is we can provide even more in these comprehensive prehabilitation appointments. We can provide supportive oncology practices in those appointments. So let's start out with some definitions. I'm not trying to bore anyone with Webster's Dictionary. What we need to do, though, is we need to understand these definitions very clearly and very precisely because when you're working with oncologists, they are very specific in their terminology, and we have to be just as precise in ours. So we're talking about integrative medicine here, right? So integrative medicine, it's incorporating these extra modalities into standard of care. We're adding things. We're giving additional support. That's very different than alternative medicine, right? Alternative medicine is saying that we're using something in place of conventional care. So we're not telling our patients, you don't need this chemotherapy. I have something else for you. We're saying, I have other modalities to help you through this standard treatment. And so that's this concept of integrative oncology, right? We are adding things to the standard of care to help improve quality of life and relieve symptom burden. And so that brings us to supportive care, supportive oncology. So what is supportive oncology? Supportive oncology is we're looking at the prevention and management of these adverse effects. We're doing this throughout the continuum of care and we're looking at physical and psychological function, right? So let me say that again, right? We're looking at, we're preventing these symptoms that we know can happen. We're looking at physical and psychological function and we're helping with the adverse side effects of cancer treatments throughout the continuum of care. That sounds a lot like cancer rehab, right? I feel so strongly about that, I'm gonna wish it again, okay? Because my PowerPoint skills from the 10th grade are paying off in this moment, okay? We are doing supportive oncology. And why am I on my soapbox when I'm talking about this? It's because sometimes we have a marketing problem, right? It is very challenging to go out and just start cancer rehab programs, right? It's not, you just don't put up a sign and people say, oh, I get what you're doing, right? But oncologists, they get supportive oncology. They get that they need support for these patients, for these symptoms. And so if we can really start incorporating that, we can provide this for our patients and we can start with that prehab visit. You know, at the cancer centers that I work, I'm listed on the door as cancer rehab hyphen supportive oncology. And I really try to embrace that because you do, you need to get these oncologists, these radiation oncologists to understand what we're doing. I literally, the other day, was with my radiation oncology colleagues. I was with a bunch of them in the room and I was joking with them. I was like, you guys, you finally get me, right? And that's the goal. What we're doing, we know what these patients need, but we need to make sure that other providers understand that. And so we're gonna go through how you can incorporate some other supportive oncology concepts into your cancer rehabilitation practice. So obviously there's lots of things that we can do with integrative medicine, supportive oncology. Specifically today, I'm gonna talk to you about how we can use acupuncture and medical cannabis in these prehabilitation visits. So again, we're going back to this patient. We have this case study. You know, when I see patients for the first time, this is so common what they tell me, I'm petrified of starting chemo. I'm so afraid of getting the effects of having nausea, vomiting. I'm so afraid of being uncomfortable during that time. And that's really the opportunity where we have in these prehabilitation visits to say, I'm the one who's going to get you through this treatment. If you are having pain, if you are having discomfort, if you are having side effects, you call me. And that is gonna be that value of that prehabilitation visit, of that supportive care in these programs. So we're gonna talk about chemotherapy-induced nausea and vomiting. I don't think it's typically something that we think about in cancer rehab, but it's certainly something that we can help address if we're using these supportive measures. So when we talk about this, we have highly-metogenic chemotherapy agents. So that's our anthracyclines, right? So lots of our breast cancer patients are getting these highly-metogenic chemotherapies. And so when we talk about it, there's this acute phase where you get nausea and vomiting. That's in the first 24 hours after that infusion. And then there's the delayed phase. That can be two to five days post-treatment, right? And so there are lots of guidelines on what we use for prophylaxis. And so your typical standard regimens are 5-HT3 receptor antagonists, your NK1 receptor antagonists. We use steroids, olanzapine. And to be fair, oncologists are mostly taking care of this, right? I'm not gonna claim that I'm taking care of this because they're doing this prophylactically before treatment. They're giving them their pre-RN medications. But what else can we do when that standard regimen isn't enough? That is where integrative oncology can come into this, can play into this, right? Because we're doing additional things when that standard treatment is not enough to help with those side effects, to be supportive. All right, so I can be very granola at times, okay? I can be very in tune with the universe and all that good stuff. And patients like that. But I also know that I work with oncologists. And so when you work in oncology, you have to know the evidence. What are the guidelines? What are people saying that we should be doing? So looking at the guidelines for acupuncture for chemotherapy-induced nausea and vomiting, this is looking at acupressure. So acupressure is when we're just applying pressure to an acupuncture point. We're not necessarily using needles. There's electroacupuncture, where we actually provide an electrical stimulation to that. So for ASCO guidelines, they give it a grade C. Selectively offering these things to individuals based on our professional judgment, that sounds reasonable enough to me to offer to a patient. And then acupressure, sorry, Society for Integrative Oncology gives it a grade B. So high certainty that there is benefit. So certainly something that is reasonable to try in addition to those standard regimens. So I just wanna go through, when we talk about this, a few studies, newer studies, to see how are we incorporating this into standard cancer care regimens? And how are we gonna be doing this in the future, right? So none of these studies are huge studies or that are standard of care changing, but it's just to give an idea of the concept of how are we actually incorporating this, right? So this is looking at breast cancer patients. They're undergoing those highly immunogenic chemotherapies. They're getting, they have their control. That's their standard of care. And then they have the intervention group, where they're actually doing acupuncture on these patients. Day zero on that time of infusion to day five. So we're getting that acute phase and that delayed phase of the nausea and vomiting. So these were the points that they use. Special thanks to my sister, who always allows me to put needles in her. And so these are the points that they use. The ones I really wanted to highlight is right on your wrist is heart six. And right there on your lateral tibial plateau is stomach 36. Those are very powerful points in acupuncture that help with nausea and vomiting. You can actually just teach your patients to do acupressure to put pressure on those points. It kind of can be a very empowering thing for patients so that they at least have something to try without taking a pill to help with these symptoms. And so it's very easy to do in your prehab visit. There's also acupressure, right? So acupressure is applying pressure to those points. In this study, they did auricular acupressure. So doing auricular acupuncture, what we talk about with the ear, basically, in acupuncture is that it's a microsystem. So you can find the entire body on that microsystem. You can find your knee on the ear. You can find your heart on the ear. You can find the spine on the ear. And so what they did was they had patients place beads on the ear and basically put pressure on them to see if it helped with those nausea and vomiting symptoms. And it did. And so what that means in acupuncture is that it opens your spirit gate. It allows you to move energy, to move emotion. And so again, there's this concept of doing supportive oncology for our patients. So even when I'm doing acupuncture on a patient for neuropathy symptoms and just working on their feet, I always include gen men because I think it's important to help our patients with those emotions. And we can provide a lot of support in those visits. So we're going to switch gears now to medical cannabis. So my full disclosure, please operate within the legality of your state, local, and organizational guidelines. So medical cannabis definitely can be utilized. When we're talking about medical cannabis, the first thing we think of is what formulation are we going to use. There's the THC to CBD ratio. There's the root of administration. So there's oral forms. There's liquid tincture forms that you can put under your tongue. The benefits of that is it gets absorbed quickly. You can titrate them fastly. There's oral capsules that you can be eating. There's vaporization forms. I don't recommend those because there are case studies that that can cause significant lung damage. There's topical creams. And then there, you know, it's relatively safe to use medical cannabis. There are some relative contraindications. One is unstable cardiovascular disease. So any patient that we have that is recently has an arrhythmia or something like that, you probably want to clear it with their cardiologist. Obviously, respiratory disease, we want to not use smoking forms or inhalation forms of this. And then family history of psychosis. It could potentially worsen things like schizophrenia. But that kind of, you know, these are relative contraindications. And again, when we're talking about doing prehabilitation and supportive oncology, the goal of this is to get patients through treatment. So I've had patients who have schizophrenia. But we kind of have to make a decision. You know, I had a patient who was having such difficulty getting through their chemotherapy. And everyone was asking me, what else can we do? And we did use medical cannabis. And I talked to their psychiatrist to just keep an eye on this. But that's what we're doing in supportive oncology, right? We're doing what it takes to get through treatment. So the other question, are patients using medical cannabis? Are they using marijuana? And the answer is yes. So this was looking at an NCI designated cancer center. And almost 25% of those patients did say that they were using cannabis. But what is really important about this is that 75, 74% of these patients said, I wish I had someone, a provider that I could speak to about this. That I could get more information on about this. And that, again, is where we can come in, right? So oncologists, they don't have the time necessarily to be doing all of these things. But we can. And you can easily do this in a prehabilitation visit. So when we're thinking about medical cannabis, the main thing we think about is that delta-9 tetrahydrocannabinol, so the THC. And then there are many other components in it though, right? The cannabidiol, that's our CBD. Actually, once you go through the second pass metabolism, there's over 400 compounds that can be found in cannabis. And it's actually thought that those compounds enhance the effects of THC on the body. This, I think, to distinguish from cannabis, right? Medical cannabis, pure, I would say, natural cannabis versus synthetic THC. So things like dronabinol. So things like dronabinol, that's synthetic. two main receptors. There's the CB1 receptor and CB2 receptors. So your CB1 receptors that we think of as more centrally located, they are located at many areas in the brain, in the cortex, in the hippocampus. on our immune cells has effects on pain modulation. So again, we can be as granola as we want sometimes, but what is the evidence? What are the guidelines? So ASCO says the guidelines for medical cannabis for nausea and vomiting, well, there's insufficient evidence. There was a Cochrane Review, though, in 2015, and the author's conclusions there is that and a study looking at this, what were they doing? Well, they used that. vomiting, let's talk about neuropathy symptoms. Again, how many times in your office do you have a patient that goes, I am petrified of developing that neuropathy? Or, what am I going to be doing if I do develop these symptoms? What can we do? Are they going to go away? Those are all things that we can be addressing and talking about in those prehabilitation visits. And why is it important that we're really paying attention to neuropathy symptoms? It's important because this can be a dose-limiting step in patient's treatment. So what does that mean? That means if patients develop these symptoms severe enough, that they are going to be stopping treatment, they're going to be getting less treatment than their oncologist wants, and that can be a big deal. And that's something that if we can help prevent, if we can prevent this dose-limiting step, it's something we want to try to do. So what's the evidence for acupuncture and prevention? Again, per ASCO, there's no recommendation. However, there is preliminary evidence that suggests there is a potential benefit. So again, something that we can certainly try and consider to do. So this is a study looking at how using acupuncture to prevent the escalation. The ones on the feed I wanted to point out, those are called Ba-Fang points. And so when I use those points a lot in treating neuropathy symptoms, I've had some pretty good success. I'll actually add electrostimulation to them. And so again, in this study, a small study, definitely, but they had 26 out of 27 patients did not have that progression. So what is the thought of the mechanism of how acupuncture works? When we're having these neuropathy symptoms, there's damage to our nerve fibers. There's damage to our alpha delta, our C fibers. And so it's thought that when we talk about the guidelines for actually to. is that, again, we have our CB1 receptors. Our CB1 receptors are attached to our, they affect our potassium channels, and so they prevent the cells from essentially depolarizing, so they're not having as much firing of those neurons. And then in the peripheral system, our CB2 is acting on our inflammatory cells, so obviously inflammation causes pain, it's a pro-inflammatory state, so we're decreasing that inflammation. And so again, typically when we think of neuropathy symptoms in treatment, it's more the CBD that we think is more effective. So this was, again, a study, a small study, where they did 150 milligrams of CBD twice daily, and these patients did have less symptoms of neuropathy, essentially. So again, kind of bringing this all together, when we're talking about a comprehensive prehabilitation program, we are doing all of those things. We're teaching our patients to maximize their function, we're doing the lymphedema education, but we can also provide a lot of supportive oncology and discuss a lot of these symptoms that patients are very concerned about when they're beginning their treatment. And that's really how we incorporate ourselves into that oncology continuum. If patients know that we're the ones, cancer rehabilitation is the ones to go to for a lot of these symptoms, that makes us all the more valuable in their course of their treatment. So I think that's all we have, and we're very happy to take some questions, and I'll invite my co-speakers up back with me. Thank you. You get the spectrum of patients, right? You have patients who want to do every single thing that they can and some that don't, right? So I don't think we're going to really move the needle on that. And I think I'm glad that you brought up the point. So when you're at major academic centers, there are these sub-specialized places. But where I work out and where I think if our field is expanding, we're working in satellite clinics, right? Patients can't go to rehab if their major institution is an hour away, right? They can't go there twice a week. I think a lot of fellowships have a strong emphasis on palliative care, right? I definitely do will in my fellowship. Oh, yeah, I went and they were like, no, no, I can't use that arm Regardless of if anyone's getting an LV bypass, what not, I currently haven't changed my screening protocol, but it is something that I'm going to be, you know, eyeballing results and such. I don't... Even patients now, they're saying, oh, well I got this preventative. How much am I looking to reduce my risk? And I basically say, I don't have enough data right now. I know that I feel good about it and I think it's a preventative step and I think it's a good thing. No, the initial eval was covered by all insurance. We didn't have a single patient whose it was denied for, which we were very fortunate. I'm really going to knock on wood as I'm... identified, and typically we just, especially if someone's naive to it, you start at the lowest dose and then you just gradually progress until if they feel improvement, because either they're going to feel improvement or they're going to get high and not like it. So that is very challenging. That's very challenging, but like so I'm fortunate in Yeah, that would make me certainly do a workup. Just because I wouldn't want to just be like, oh, you got your lymphedema. You know, I'd want to be like, hey, when was the last time we imaged your axilla? Anything else going on? I'm uncomfortable with this. Not that it can't happen, certainly. They're still at risk over the course of their lifetime. But at that point, I would absolutely be looking at alternative explanations for it just to make sure before saying, yep, you got it. Because yeah. All right, thanks, guys. Thank you.

cancer rehab

donations

breast cancer prehabilitation

shoulder function

upper mobility

exercise counseling

lymphedema assessment

lymphedema management

acupuncture

medical cannabis

supportive oncology