Good morning, everyone Well, first of all, thank you so much for coming to this Session this topic today is a really near and dear to my heart or the next one hour Hopefully we can have a very Engaging conversation because we have a really nice group I think it'll be helpful if you know the people who are sitting in the back kind of come in the front we can have a nice dialogue and a nice engaging conversation so Cancer pain and cancer rehab. These are two big topics which are really near and dear to my heart and our esteemed faculty here have spent a Really great thought on on Developing these these two models together and where they are right now so over the next about 45 minutes what we will try to do is Give you different perspectives first perspective from the from a fellow in training the second perspective in a private practice setting the third perspective in a community-based hospital setting and Then we we will have an institutional academic setting model Discussed and then finally we'll try to bring pieces together And give you hopefully and hopefully make a case to have a combined speciality subspecialty of cancer pain and rehabilitation So I'm him on the Kali. I'm one of the spine and pain doctors I'm also I do quite a bit of cancer rehab in upstate New York. I like to call them from Napa Valley of the East From Finger Lakes region. I know there there will be some people in the audience who would differ from that statement but I would still like to Take that take that so I want to pass on this and have our esteemed faculty introduce themselves and Dr. Salina Hi, my name is Mike Salina, I am chair of physical medicine and rehabilitation at Cooper University Hospital in southern, New Jersey Good Morning, dr. Gurtej Singh lead interventional physiatrist for the Centers for Advanced Orthopaedics in the Maryland DC Northern Virginia area I'm Eric Shaw. I practice pain and PM&R at the Shepherd Center in Atlanta, Georgia Where you see a lot of spinal cord brain injury and community-based kind of severe pain Dr. Gurtej Singh Thank you With that we're gonna quickly jump on to our first Presentation now you must be thinking, you know, this presentation says soon Sheen She's actually one of the fellows at MD Anderson. Unfortunately, she will was not able to Reach and and attend this conference today So I'm not as good-looking as her but I'll try my best To hit all the the points which she wanted to make as a in-person training fellow at MD Anderson So some of the challenges in cancer pain and rehabilitation training we know that we have close to about two million new cancer diagnoses in the United States each year and When we talk about the impact of Cancer whether it's the cancer itself or the treatments of cancer it leads to Significant functional impairment. So the functional needs and the rehabilitative needs of these patients are pretty significant About 50% of patients continue to experience pain and functional limitations after their cancer survival there are a lot of challenges when it comes to training at all Different levels starting from residency all the way to fellowship. We don't have a specific curriculum which brings the constructs of cancer pain and cancer rehabilitation together There are actually no ACG me requirements specific to cancer rehabilitation in the pain fellowship programs And there are there is no specific ACG me requirement on Cancer pain in the PMR residency or some of the non-accredited cancer rehab Programs so you can see that there's a huge gap So even the the the trainees or the experts in the field who are coming out They are not getting trained on the true length and breadth of the treatment Armamentarium which can be offered to these patients in the under the umbrella of cancer pain and rehab We we have a limited number of cancer rehab fellowships in our country There are about nine non-accredited cancer rehab programs and the question Which often gets raised is that do we really need a year-long fellowship for cancer? Rehabilitation are there any other skill sets which can be added onto that curriculum to make that specific fellowship much more Robust and increase its value proposition which can Allow the PMR residents to seek that specific fellowship more aggressively So there are a lot of gaps in the current training cancer patient specific conditions and comorbidities disease or treatment specific complication and how to apply those into specific patients and that requires a Comprehensive understanding of both the Path of physiological state but also an understanding of the impact it will have on a rehabilitation plan So how to improve training perspective? Increase exposure through training with more dedicated cancer rotations Improve our understanding of cancer population specific pain and rehabilitation needs Improve physiatry presence throughout the the patient's cancer journey. So I think in in summary What dr. Sheen? Wanted to make a point here was that there are there are huge gaps on both sides in the training of cancer pain in the fellowship programs and in cancer rehab so there might be an opportunity to bring these two disciplines together and make a really highly valuable and high high value proposition proponent to to our to our residents to seek training in With that I'm going to switch gears and pass the the microphone to dr. Singh he's gonna go over the role of cancer pain and the concepts of rehabilitation In a private practice setting we will take questions for the panel at the end of the presentation Good morning, everybody Good morning, everybody Thanks, okay As Hemant had mentioned I'm dr. Singh. I'm out of the Baltimore suburbs work in a large private practice group I did my Interventional pain fellowship at Beth Israel in New York City. It was in the Department of Pain Medicine and Palliative Care Unfortunately, our fellowship no longer is there and from what I've just read online Beth Israel as a medical center is soon to not Be there as well But we had exposure to the hospice and palliative care team And so it kind of would extend from what you know Dr. Akalia was saying not just sort of in the cancer and the rehab that even sort of hospice and end-of-life I think physiatry and and PM and our specialists play a critical role My ask today was a case-based argument for the cohabitation of our specialties So here's our first case 62 year old female metastatic lung cancer with Mets to the thoracic and lumbar spine I presented in two different scenarios because I've been presented with these kind of patients in two different scenarios You have your early diagnosis situation And in these sort of settings having worked with radiation oncology there there is value in offering patients a tumor ablative procedure with vertebral augmentation And I'll show you a picture on the next slide about what that looks like One can do this ideally prior to the third XRT treatment There have been studies that show that once you kind of get into the meat of radiation therapy Integral weakness within that bone doesn't lend itself for ideal Intervention at that point if something were to collapse or a neurological loss were to occur You really would need surgical intervention at that point So if you can try to get to the patient early It allows them to experience less Procedural pain while they are receiving their cancer treatments. So it allows radiation oncology and even oncology to titrate down the amount of short-acting opiates that patients might need to make it through those treatment sessions and Then of course then you have the second option, which is okay. We have given them all the grays of radiation We could possibly give them now. What can you do? They still have you know Bone pain. So the technique the procedure does become more challenging at that point you kind of have to use some different equipment to depending on the the morphology of the of the tumor But it can still be done to achieve pain control As promised here's kind of what a procedure would look like so you can see both t12 L1 and L2 are being treated that top left are the Introductory needles and the drills that are used that top right picture at the very top t12 You can see if you can see there's a small dot on the posterior third It's from that point forward towards the anterior end plate where you're getting the the ablative The heat energy to to tumor ablate and then that gets repeated at l1 l2 and then you can see the bottom two pictures Offer you what the cement fill afterwards would sort of look like As I was listening to dr. Kali. It came to me. There was one other case and I'm sorry didn't put it on here of a gentleman with metastatic colon cancer and He was admitted to the hospital so I would go around on him and this was in my former life when I used to work for a hospital group and Now I have a smile because I'm in private practice So I was in his room You know, he was on a PCA for the pain. It was me and the colorectal surgeon. It was him and his wife and We both were making the case which procedure you should have first Should you have the debulking procedure that the colorectal surgeon is offering you should you have the tumor ablative procedure? for pain control that I'm offering you and Much to the dismay of the colorectal surgeon. The the patient wanted to have the tumor ablation procedure done first This was towards the end of my stay at that institution and then obviously moved on to private practice oddly enough About six to twelve months later. The wife had come through our office It turned out that she was affiliated with the radiology center that rented space in her basement and so she was coming through just to introduce like hey, don't forget you can have your MRIs done downstairs and She totally stopped dead in her tracks when she saw me and she said you used to be at that other institution I said, yeah, how do you know? She said my husband was the one that chose to get the tumor ablation done first and then a few days later He had his colon, you know cancer resected and I was like, wow, you know, thanks for the follow-up because unfortunately, you know I couldn't see that She said he did pass but he didn't pass in the pain that stuck got him stuck in the hospital And so you can see that even these are impactful to the family, right? So there's so much here that's intertwined and how PM and our physicians can collaborate, you know with all of our other colleagues Second case is also a patient of mine She has multiple myeloma. She's been treated at our, you know, the local hospital Cancer Center high-dose long-acting Fairly low-dose short-acting all things considered opiate and then a cocktail of non-opiate medications She had significant painful peripheral neuropathy Offered her a high-frequency spinal cord stimulation trial during the trial. She was able to stop her short-acting She was able to get a much better night's sleep Her biggest issue was you know towards the end of the day and trying to get sleep that the pain in her feet were just inhibiting her ability of getting quality rest and so then that kind of Became a it piled on to then even missing, you know treatment sessions because she was sleeping during the day And not at night and what-have-you So we went of course we went on Implanted the device she Actually came and saw me about two weeks ago because her husband also sees me and she said dr Singh I was dancing with my oncologist last week because you know, I finally am cancer-free and She said but to be pain-free in my feet and get sleep. I should be dancing with you, too I'm like, I don't know if you want to dance with me But but just you know These are the stories that do come back right and so you can see the power in the impact that intervention can have on these cases Here's an example of what a spinal cord stimulator would look like both on the trial and implanted specifically for an individual with You know painful neuropathy from a cancer etiology A Third case goes into targeted drug delivery So again, you're kind of you're seeing a spectrum of folks, you know, some who you can intervene with metastatic interventions Excuse me. Some of you can intervene with Ablative interventions others you can intervene with neuromodulatory interventions. Here's another form of neuromodulation Where we can take a patient who is doing well, right? I mean at 48 this individual has years of life left. They're managing, you know, their their pathology But the pain is what sort of limiting them from kind of being more active in life And so the side effects from these oral medications are able to be reduced you know this individual it was for him, it was simple to be able to do a Targeted drug delivery trial Back in the old days when I was a resident we would admit patients to the hospital and put them You know an indwelling catheter and leave them for three four days On an indwelling catheter to determine nowadays, unfortunately with Insurance reimbursement were sort of stuck you get a one-shot trial. So we did the one-shot trial Truth I wasn't really worried whether that worked or not, but knowing that I could reduce their oral doses Significantly allowed all of the side effects So the GI side effects the cognitive side effects the urinary retention side effects all come down When we're able to offer patients targeted drug delivery And Then case case four is a bit of polypharmacy So I know this is an odd case because all my other cases show how you can reduce medications and this case says well Actually give them more and I think that's important, right? I mean each patient needs that unique and individualized therapy. So an individual where Intervention is not necessarily the the right option for them Being able to add, you know polypharmacy with the neuropathic agents muscle relaxers Alpha-2 agonists these are ways in which we can offer patients better pain control less reliance on necessarily the opiates But it just kind of makes sure that we we cover all the bases when offering these patients treatments Finally would be the peripheral nerve targets. So there are multiple different types of diagnostic nerve blocks we can do pulse radiofrequency spot a peripheral nerve stimulation and of course Neurolysis, one of the most common ones is celiac plexus for pancreatic cancer Not done a ton, I don't know how many pain fellows are out there, you know learning celiac plexus blocks But you know, that would be something that would be critical in an interventional pain fellowship for someone who wants to manage You know chronic cancer pain And again with each of these, you know, there are opportunities here As in private practice, it's more I don't say it's a passion of mine, but To be able to you know See these patients and the reward you get in Them coming back to dance with you or in the wife being able to say, you know, you offered my husband Relief of his pain prior, you know to him passing You have to take that initiative to go out to meet the oncologist to go out meet the radiation oncologist One of the things I learned when I first tried to build this relationship is that they're going to vet you In how much do you really care about this patient? Because they feel they're fully invested Right, so patients have their cell phone numbers that kind of stuff So all of my all my referring oncologists and radiation oncologists, I all have my cell phone number They can text me call me any any time, you know during the day I've shown up to, you know, tumor boards, board reviews that, you know, they do at seven in the morning or 7.30 in the morning. Even if I say nothing the entire time, they knew, okay, Dr. Singh was here. So if there is a case, we can always call him. So you do have to make that time investment. And if that's something that's a passion of yours, you'll be rewarded at the end. Thank you, Dr. Singh. So you guys saw that Dr. Singh validated the importance of interventional cancer pain management, especially on the private practice side. Next, we'll move on to Dr. Shah. He's gonna make a case of how to bring these two specialities of cancer pain and cancer rehab together in a health system setting. Mm-hmm. Where is it? Where is it? Nope. There you go. Yeah. I did hit slideshow. Yeah. Oh, no, I had presented it, okay. Yeah. Hold on, I'll find it, I'll find it, hold on. Really? I just uploaded it a little while ago. Yeah. It was, right? Yeah. Okay. Yeah, that'd be great. Oh, there you go. Perfect, okay, yeah, thanks. All right, so it's a beautiful Shepherd Center. That garden is now gone. They're building a new building for us. So we're gonna have a brand new space in about a year and a half. Okay, so a lot of us work in the community in private practice or community-based hospitals and sort of integrating these things that we've talked about outside of an academic center where we have all the tools in place might be a little bit difficult. And I'm gonna make the case why a PM&R physician, we're rebranding again in case nobody told you, from physiatry to PM&R, because there's an ever-present confusion about what we do, and how PM&R and pain physicians specifically can help to run the team to not only help to control pain as Dr. Singh was explaining, but also to run the rehab aspect of the team with a therapist. And we're talking about all the parts that you need. Next slide, please. All right, so we're gonna talk about the problem. We gotta put the team together. We gotta have all the right parts. And if you don't have those parts, you're gonna have to petition the powers that be to hire those parts. You gotta build the relationships because we all know how obstinate oncologists can be about their treatment paradigm. You gotta actually execute the care, whatever that means, and then we're gonna manage these complex patients. Okay, next slide, please. Right, so you gotta get access to the patients, right? So depending upon where you are, like Dr. Singh has reached out and made all these great relationships with his oncologists and surgeons. So they're sending him patients. But if you're kind of starting this program anew, the oncologists are like, no, I got it. Chemo, radiation, opiates, we're done. We don't need anybody else, right? We know for a fact that patient care can be delivered much better, much more succinctly, much cheaper, with much better outcomes based on the cancer rehab literature that we know. But integrating that with modern techniques of pain management and putting that together is a little bit more complex. So you have to, nope, gotta build the team, gotta understand the evidence. Now we've talked about, cancer rehab we have some good evidence for, but cancer pain and cancer pain rehab specifically, there's not really anything published, right? Stuff that I looked up was from the 80s and the 90s. There's a problem. These patients are in pain. They're underserved. They're not getting the opiates they need. Well, yeah, that's not really where we are today in the 21st century. You gotta deal with the psychological issues, right? So having the right counselors in place can be helpful. You gotta have a supportive team to do the whole thing. You gotta have, ultimately, the resources, case management, et cetera, to get the job done. Next slide, please. Okay, so we need a doctor, right? Physical medicine, rehabilitation, and pain combo specialist would probably be the most helpful or at least a pain specialist in combination with a PMNR. Maybe you need a APP. Maybe you need a couple of APPs, depending upon how big. You definitely gotta have some nurses and some MAs to help with patient flow and taking care of all the calls. You gotta have therapists, right? So you can't just treat a problem, have this debilitated patient with a pain problem, amputation, lung resection, whatever the case may be, spinal cord injury, stroke, or hemiparesis, and not be able to get them better to be more functional. You gotta have psychologists. These are end of life. Family's going through a lot of trauma. It depends upon the age of the patient, obviously, and the family dynamic, but having a psychologist part of the rehab collective is so critical. I think we'd all agree on that in general. And then, yeah, so for both the patient and the family, whether it's end of life or problems with pain after curative or remission therapy, they still have peripheral neuropathy, post-operative pain, phantom limb pain if they have an amputation, they may have a spinal cord or hemiparesis injury. And so all these things are relevant within the PM&R space. Next slide, please. All right, so depending upon what practice setting you're in, and this was true maybe 20 years ago, maybe less true now, there's still a lot of misunderstanding of what PM&R doctors do and how we can add value to the team. And this is something we're struggling with as a community, all right? So oncologists generally treat the pain with opiators, rhymes with haters specifically for a reason. Now, obviously in this population, opiates are very necessary and have a significant utility, but they also have significant side effects. And especially when we're talking about the final months or years of someone's life, we wanna improve that quality of life and not diminish it with side effects that opiates can cause. So with all the treatments that we've been talking about, therapy for swallowing, range of motion to help get back on your feet and moving, nerve blocks, whether it's peripheral nerve block or stimulation or ablative therapy, right? This is the way anybody, Mandalorian fan, anyway, it's a baby Yoda. Nobody, anybody at all? All right, nice, okay. So, but you gotta, like, if you don't have the team, you gotta build it, right? And so these hospital CEOs aren't just gonna like, okay, here's a couple hundred thousand dollars, go hire your team. They need a business case, right? So you have to show what the problem is, how these patients are being underserved, how you can actually bring revenue into the hospital, improve quality of care, and reduce readmissions, all these things that penalize hospital systems, okay? And then we gotta have, you know, we're, PM&R doctors are specialists at building a team and leading a team, right? So you're gonna have radiation oncologists, oncologists, general surgeons, neurosurgeons. And we're part of leading or helping to direct the care team, not the surgeons per se, but the care team after the intervention to help that patient have the best quality of life, okay? And so obviously, if you integrate the PM&R into that, it's gonna make things better for the patient. And these are the, not only qualitative and, or quantitative issues that you can support to the hospital board and the CEO, but also the qualitative, that you're gonna get better responses from your patients and their families because they feel that they've really been taken care of. Okay, next slide, next slide. Okay, so, you know, you gotta have, as Dr. Singh was pointing out, you know, we have to know what the problem is so we can target the intervention directly to it. So is it peripheral neuropathy from chemo, the patient's in remission or cured, but they have lingering effects, they could have, and so here we see the topical, we see some options. Post-theracotomy, endobrachial costal, costobrachial neuralgia, right? Something very common after mastectomy. And breast cancer, I have an unfortunate lady right now that's had recurrence after a decade that still had her expander in for a decade, and so she can't have an MRI, and she had this persistent axillary pain and ultrasound showed recurrence of cancer. So I was able to easily do the T2-3 intercostal block for her, and at least short-term, she had complete relief of pain. So we'll see how she does long-term and how her cancer treatment goes. So, and obviously lots of other things, okay? So spinal cord stimulation, peripheral nerve stimulation, intrathecal therapy like Dr. Singh was talking about, and on down the line, okay? So, but to have the interventionalist, either the same person as the physical medicine doctor or on the same team as the PMR doctor, can really be helpful to kind of put all the pieces together to treat that patient not only for pain relief and controlling the pain and maybe managing the opiate prescriptions, but also directing the therapist to help get the patient the best quality of life and outcome. So if you put all that together and you say this is gonna be a cohesive plan for the patient, the hospital may say, oh yeah, this makes a lot more sense. And then the PMR doctor can lead the team. Next slide, please. Or maybe that's it, no, yeah. So integrating the PMR doctor into the team has a lot of advantages for obviously patient care, efficiency, and long-term better outcomes. Interventional PMR may have a specific and unique contribution to this team because of the training that that interventionist might have. There's clear evidence for intervention and rehab is not present, but for cancer rehab specifically, there is. So obviously these are complex issues that may require and may benefit from further specialization that Dr. Salino is gonna talk about next. Next slide, please. Thank you. Thank you, Dr. Shah. So we're gonna, that was an excellent presentation on how to develop a cancer pain rehabilitation program in a community-based hospital setting. Now we're gonna make things even more challenging and complex. We're gonna add layers of more committees and how to maneuver a tedious path through an academic institute. So Dr. Salino is gonna take us through that path and share the challenges of having these two subspecialties come under the umbrella in an academic setting. Dr. Salino. I wanna thank my co-presenters today. They kind of just put the ball up on the tee for me and let me swing away at it. So my task for the next little bit is what concerns do you need to have from an institutional and academic perspective in taking the good clinical basis that was just described to you and actually making it come forth to be a subspecialty of itself. These are my disclosures, nothing super relevant to this talk. It is my obligation that anything I say that does not exactly represent the opinion of Cooper University Healthcare. That's one of the things that I have to say every time now that I have a position of leadership. So those who don't recognize history are doomed to repeat its failures. So we're gonna do a little history lesson for a moment and how do subspecialties actually evolve? Well, it actually starts with us attending, practicing physicians saying, there's a common interest that all of us have and can we bond together to create that interest and move everyone forward? That then becomes, well, if we're all kind of doing the same thing, we need to create practice standards so that patients get treated with good certification process. It's a little bit unofficial, something like a certificate of added qualification or some similar nomenclature saying, hey, you know, we put these standards together. This then, well, if we do it, our trainees are gonna wanna do it. And then a training pathway, stuff down in Atlanta taking care of these folks. How do I become Dr. Shaw? Well, that then is a specialty branch emerges out of it. It probably starts first with an unaccredited fellow distinct training pathway. I think the best example that all of us can rule, 60 years ago, sports medicine was the complete domain of the orthopedic surgeon. But about 40 years ago or so, and this is about when I was a medical student, maybe even a late college student, a group of physicians, non-ABMS recognized group called the American College of Sports Medicine began to coalesce those efforts of non-access. They actually had a process called, how do you become a certified team physician? They actually went to a couple of courses of vacation. But then this interest began to infuse into other specialties, pediatrics, physical medicine and rehabilitation, emergency medicine and others. Well, then if the residents wanted to do this, they began to create fellowships. Initially, they were unaccredited fellowships where individuals spent a period of time, usually a year, sometimes shorter, sometimes longer, where they really focused all that efforts. And then as that body of evidence began to grow, a formal proposal was put forward to the American Board of Medical Specialties saying, let us create a new subspecialty called sports medicine, where individuals from a number of fields and the fields I mentioned, peds, ER, internal medicine, physical medicine and rehabilitation can apply to a fellowship and literally have a minted certification saying that they are a sports medicine physician. But it started with what's going on in this room, right? Just a coalescing of interests of similar minded physicians. It probably took 20 years for this to evolve into a boarded subspecialty. And that's maybe a little bit of a longer timeline than hopefully something like this could evolve into, but this is where it came from. So, if we really think of this as a subspecialty, not a new specialty per se, what really the fundamental piece of that is the fellowship. The linkage between what we're doing now, a coalescing of interests of practicing physicians and generating that subspecialty. So, I'm gonna give you a little kind of under the hood look of what a fellowship looks like from the academic perspective. You know, what chairs and division chiefs do is they create business plans. And that's a lot of what we'll kind of show you under the hood. So, primarily, and this is super important, fellows are considered sort of resident plus, meaning that they are not new staff, they are not co-members of the department. They can have an academic appointment, but they're really considered resident plus. And the educational needs have to take precedent over the service line issues. That's sort of true. I'm gonna show you where it really doesn't exactly hold true in just a moment. My colleagues have done an excellent job in pointing out the clinical need for it. Well, if there's a clinical need for it, then we need an educational process to fit that clinical need. We have to remember that fellows have to be considered students more than employees. Remember, they are sort of a hybrid, right? I mean, they get a salary, they get benefits, and that sort of stuff. So, they are an employee, but they're recognized more as students as opposed to employees. They also need to be covered under the umbrella of an existing residency, especially if it's an accredited fellowship, maybe an unaccredited fellowship doesn't need that umbrella of an institution, but more often than not, it does, so that there has to be a sponsoring program. There's actually a couple of different ways that this could happen. Could there be a direct entry into a unique subspecialty cancer pain rehabilitation directly from residency? Maybe it's a little bit of modification of our concentration within some of these fellowships. Like, for example, a pain medicine fellow could choose a concentration in cancer pain, similarly for hospital and palliative medicine. Maybe those are other fellowships that they do an extra six months or a year following those fellowships. Maybe there's even a pathway for some oncology trainees who might be interested in this sort of thing, too. So, these are all the things you need to consider as you're creating a fellowship. So, probably, in all likelihood, it would start with unaccredited pathways first, and once those unaccredited pathways become fairly well-recognized, then a full accreditation pathway can occur. You need to make sure that you have three elements. Number one, the things that Dr. Shaw talked about, the infrastructure around this clinical need. Do you have enough patients, a big enough patient population? Do you have faculty who are interested in teaching this? Do you have the space and the allied health professionals and all those sorts of things? You also need candidates. I can remember in the early days of spinal cord injury fellowships, yes, we have this accredited fellowship, but we didn't really have a whole lot of candidates. You don't want to go through all the effort to create something like this unless you know that there's an interest among existing residents. And lastly, and most importantly, I think, is the business plan to cover the cost. And again, that's what chiefs and division chairs and deans do. So more about the costs and the business plan, again, kind of looking under the hood. Hospitals receive funding from CMS to support residency training. This is the so-called residency cap. Caps for existing hospitals were set in the 1990s and don't often change. The vast majority of existing hospitals have many, many more residency fellows than their cap can exist. For example, at Cooper, our cap is something like 440, and we have over 600 residents. So we are funding 200 residency slots over and above our cap. Very rarely do GME slots open up. A good example of the not-too-distant past is when Hahnemann University Hospital closed a few years ago in Philadelphia. Those GME slots actually were open to bidding, and there was intense bidding amongst the Philadelphia hospitals, and they were distributed amongst hospitals in the Delaware Valley, and Cooper got some of them. Probably some rural hospitals will get some additional funding, but typically, once the cap is set, that's what you're fixed with. So if you're at an existing hospital, odds are you are over the cap. So what does that mean for us? Now you have to make the business case of why this fellowship makes sense from a business perspective. New hospitals or hospitals that have never had a GME program can petition CMS for GME allotment. These are the so-called virgin programs. So if you happen to be hired at a program that doesn't have GME slots, there is the possibility to petition it. This allotment occurs in only the first few years of a new hospital or a new GME program, and then it's fixed again. So you've got a really short window to maybe get an argument for a GME slot. And I know some people might have thought, well, hey, let's go align with that new hospital that just came up across the street. They don't have residents. We'll take their slots, and we'll send our residents over there. It's not as easy as you think. CMS looks really careful about any commingling of residents between new and existing programs, and you actually have the potential, I'm not saying anyone would do this, that's actually federal fraud if you try to mix that too much. You really need to be careful if you're trying to do that. So the business plan. I'm going to make the point that I think this is the harder piece of it. I think my colleagues have done an excellent job in saying why we need it from a clinical perspective, and if we need it from a clinical perspective, then we need it from an educational perspective. So you go to your dean, and you say, hey, I think cancer pain rehab would be a great fellowship. And they're like, great. Go talk to the finance people. They're not going to argue with the educational piece. You have that body of literature. It's the business plan that gets a little bit difficult. And the basic point, obviously, you have to have a mission statement and an expression of what the educational need is, but the true meaning of the business plan is the cost expense versus income and revenue, and we'll go into that now. So what are the costs associated with trying to do this? Well, you've got to pay these folks. And fellows will be considered either a PG-5 or PG-6 trainee. So whatever the PG-5 orthopedic surgeon or neurosurgery resident's getting paid, you're going to pay them too. That's what their costs are going to be. Obviously, you have to pay them benefits. They are somewhat of an employee, and that's usually a fixed percentage of salary. Malpractice would be an intriguing question. They probably have a little bit more malpractice cost compared to a traditional PM&R trainee, but probably not as much as a full procedural specialty. You're going to have to make an argument to the malpractice provider. They're going to look up, what is this cancer pain rehab specialty? I don't have a line item for this. You're going to have to do a blend of what the malpractice cost might be of that. You're going to have to pay a percentage of someone to be a fellowship coordinator and keep all the documents together. You're going to have to pay some faculty member to be the fellowship director. And you might need to think that you need more space. Maybe we need more time in the ASC. Maybe we need to have more equipment. Maybe we need to have more support personnel. That I can't specifically map out for you. You have to think that through on your own. But these are considerations that you have to go through. You know, when you think about this, you're certainly in a few hundred thousand dollars worth of costs for a single fellow when you add up all these costs. That's going to vary, obviously, location to location. So where do we make money with this? Well, accredited fellows cannot bill independently. They're not considered staff where their services result in direct revenue. Unaccredited fellowship, you have a little bit of leeway there. I'm affiliated with an unaccredited fellowship. And you can give them some responsibilities where they could do some independent billing. But obviously, that's got to be a minority of what they do, right? You can't say, well, you're going to do 80 percent of, you know, time in this subacute just generating your own salary and you're only going to do 20 percent cancer pain rehab. Well, you've kind of negated the point of the fellowship at that point. So really, your only source of revenue generation are either A, increase the billing of attending staff or B, cost savings to the hospital. So again, how does this happen? The most important thing when you're considering this is you need this data. For example, if you could say, if we get a cancer pain fellow and we can get procedures like my colleagues described quicker to current inpatients and they can get out of the hospital faster, they can get up and move a little bit better, they'll have less comorbidities, now you're starting to get the attention of your chief financial officer. Because remember, if you decrease length of stay, now you've increased capacity. If you get the patient out of the hospital, you have a potential for better reimbursement on a given DRG. If you decrease the number of readmissions that patients have or hospital-acquired comorbidities, hospitals will get less of a penalty for those sorts of things. Maybe now that if you have an attending and a fellow working side-by-side, you could run two rooms more efficiently, but you have to think through all of these possibilities. The key thing is when you're starting out, you need to know the data ahead of time so that you can show a difference. For example, what is the length of stay of cancer patients in your hospital who receive a pain consultation? If you know that baseline data, add in the fellowship and that length of stay comes down, you've made your case. So if you're thinking about doing this, you got to have that data ahead of time. Now in olden times and say 10 years ago when EMRs were really in their infancy, that was sort of hard data to get at. Now with most modern EMRs, you can go to your information services and say, give me this kind of data on a quarterly basis so I can keep track of it. So having that data is super important. Maybe some unusual possibilities for revenue, usually probably good for startups. Philanthropy, again, an unaccredited fellowship that I'm affiliated with a little bit, was actually initiated by a six-figure philanthropic grant to get that fellowship up and running. Now it's in a more kind of self-sustaining mode, but if we didn't have that initial seed money, we probably couldn't get it done. There are some society grants, including maybe even in the cancer world themselves that you could get some seed money to get this start. Maybe some internal seeding funding. Go to your hospital's foundation and say, look, here's the clinical benefit. These guys sent it to you. Let me get this up and running as a formal educational program, and I'll show cost effectiveness. I'll show less comorbidities. I'll get the patients out of the hospital easier. Give me some money to get this started, and then it will become self-sufficient. Industry support, there's not really an exact industry support mechanism for that. It gets a little bit tricky. Some industries, medical device and pharma codes, allow for unrestricted educational grants. Sometimes you can use that to help support faculty, but you can't have it support by direct salary line, those sorts of things. You have to know both what the companies are willing to do as well as what your hospital will allow. It gets a little bit tricky. You have to bang on a lot of doors to get this done. Having said all of that, it's a reasonable thing to do if you think it's worthwhile in your particular institution. Again, you have to have all that infrastructure in place that Dr. Shaw and my colleagues talked about. This is where I work, where it's always sunny. Thank you for the opportunity to present. Are we taking questions now, or you have a presentation now? Thank you. Thank you, Dr. Salino. That was actually a cookbook. I think we can actually close the session and we can all start working together to form a subspecialty of cancer pain rehab. In next quick 10, 15 minutes, I'm going to quickly go over a 36,000 feet overview of cancer rehab, cancer pain, and hopefully we'll bring all the constructs and all the discussion points which you heard together and hopefully make a case today that we do have a huge need to develop this subspecialty of cancer pain rehab. These are my disclosures, nothing pertaining to the talk today. Some of the learning objectives which we have already gone through. I'm going to quickly jump into the Institute of Medicine report which came out in 2016. If you guys are practicing cancer rehab, I think it's a really, really great report which you all should read about. It basically recommended that survivorship is a distinct phase of cancer care. The second recommendation was that everyone should actually be given a survivorship care plan. What does this actually mean and what is this term survivorship? If we look at the burden of the disease, as of January 2023, there are about 18.1 million cancer survivors in the United States. This represents approximately about 5.4% of the population. By 2032, we will be looking at close to 25% increase in this number and this number will increase to about 22.5 million cancer survivors. This is a nice graph which gives you an idea of the scope of the problem at a global scale. So what exactly is this survivorship care? You can see this is a nice graph which talks about the phase of care in the journey of a cancer patient. Once a cancer is diagnosed and either they are in cancer remission or they have reached a stage of chronic or intermittent disease management, that's where the compendium of survivorship care comes into play. The reason why it's important is because of the scope of the problem we will be dealing with in the next 10 years. If you look at the certification bodies who certify cancer centers in our country, this is the commission on cancer from ACS which provides that accreditation of a cancer center. So if you are in a hospital which is actively seeking an accreditation for cancer center, they have to meet all these criteria put forth by COC. One of the criteria is that they need to have a rehabilitation specialist participate in every cancer committee meeting. How do you define this rehabilitation specialist? This definition is a little loose. It incorporates your specialists ranging from physiatrists to all the way your therapists and it can also be a rehabilitation nurse. This is a huge opportunity if the leaders of APMR and the advocacy and policy committees are watching this, then I would encourage and I would call it's a call of action to them to look for opportunities to work with COC and maybe have some studies put together to validate the importance of having a rehabilitation program run under the guidance and the leadership of a physiatrist and how it would change the overall outcomes. That way we can have a much more sustainable path of rehabilitation specialists, especially physiatrists leading that team in the cancer centers. When we talk about appropriate referrals for cancer rehab, any patient who is unable to return to their previous activities of daily living including their work, home, recreation or social activities will be an essential referral source for that cancer rehab program. So ideally in a cancer center, if you can insert the cancer rehab program into the survivorship care plan, it becomes almost a self-sustainable model in itself. You encourage your oncologists and your rehabilitation teams to work together. You develop these interdisciplinary teams, track the outcomes and publish them. So that's how you can have a self-sustainable model right there which has inserted itself into the survivorship care plan which is deemed necessary to maintain your COC certification and accreditation of a cancer center. Let's talk about evidence. I think I'm not going to spend a lot of time going over the entire evidence of the importance of cancer rehab. This was a nice study published way back in 2010 which basically concluded that more than 90% of patients who were in this tertiary care rehab center needed cancer rehab, but unfortunately fewer than 30% received it under the auspices. So there is definitely a huge need for cancer rehab, but most of these patients are not getting the services which they need. So the question is why? And I think this slide kind of sums it up. We have really complex structures of reimbursement and payment. Unfortunately, the reimbursement structure of cancer rehab is very complex. And in my opinion, it becomes really hard to have a self-sustainable model which is only geared towards cancer rehab. As Dr. Salino kind of pointed out that a business plan is really critical for any new subspecialty or any new initiative in a organized medicine sector. So I think that's where it's important to bring in higher margin therapies or treatments, combine them with lower margin therapies and package them together so that they become more self-sustainable. And that's where the role of cancer pain and some of the really innovative models of integrative care come into play. My colleagues have talked about all the really advanced and some of the needed interventional pain treatment options. I'm not going to go into the details of it, but I do want to spend about 30 seconds, maybe about a minute, on targeted drug delivery because I think it's a huge value proposition in our field. We as physiatrists are already experts in managing intrathecal baclofen pumps. So it's a direct extension of our expertise in learning the cancer pain management through this therapy. So why intrathecal route? I think I'm probably gonna be preaching the choir the importance of intrathecal route compared to the systemic delivery of medications. We are bypassing your first pass metabolism, we are bypassing your GI tract, and we're delivering the medication directly into the spine where all the pain receptors are concentrated in the dorsal horn so you get a much more precise, much more predictable, and much more elegant pain relief through this therapy. And I think we as physiatrists have the extra edge over the other specialists who are coming into a pain fellowship program in learning this therapy. Cost-effectiveness, it's a no-brainer. Targeted drug delivery group had fewer inpatient visits and shorter hospital stays, and this goes back to the business plan where Dr. Salino talked about. If you can prove to your hospital administrators that the therapies which you will be bringing together under this umbrella will decrease the hospital stay and it will also decrease the inpatient visits, you can make a really good business case for sustainability of this therapy. Overall, TDD group in these two seminal studies published under the leadership of Dr. Lisa Stearns, who is a pioneer in cancer pain, she was able to show that the TDD group had a mean total cost savings of about $63,000 at 12 months. Who is the right candidate for TDD in cancer world? This was a nice analysis done on one of the tertiary care centers where they saw patients who are reaching above about 150 morphine equi-analgesic dose, the odds ratio of converting them into a targeted drug delivery was more than three. And this was the poster we actually presented in NANS 2020, so you can see, you can identify all these patients who have specific cancer types which are highlighted in orange. If they have their maximum daily dose of morphine more than 150, and if they have more than two visits specifically for a cancer diagnosis, I think these patients, we were able to show decrease in the overall cost at the end of 12 months. So you have already made a path for sustainability for these patients through those channels. When it comes to models of integrated care, I again would like you to kind of pay some attention to the IOM report, which came out about six years ago, which focused on the integrated patient-centered and evidence-based multimodal approach to address chronic pain. The success of any chronic pain program is gonna be dependent on the individual aspects of these integrated evidence-based multimodal interdisciplinary care pathways. If you can build these pathways within the construct of your institute, then you will have a much more sustainable path of successful outcomes in your chronic pain patients, and you can apply that and include your cancer rehab paradigms into that as well. Integrated is not necessarily equate to co-located. It's basically coordinated. I mean, in this day and age, with really integrated EMR systems, you can actually have a lot of these services coordinated through your EMR and all the systems which you can put in place with technological platforms. So there are some gaps between the evidence and practice. There is growing evidence to support integrated coordinated multimodal and interdisciplinary models of care, but there is significant organizational and provider barriers, and some of the patient-related barriers as well, which can lead to the lack of access to these equitable approaches. So one of the models which we kind of incorporated in our setting was a cohabitated model with palliative care within the umbrella of a cancer center. So a pain doctor who also has expertise in rehab going into the cancer center and seeing the patients within the umbrella of cancer center with palliative care helps to decrease the overhead cost and have much more sustainable referral source within those paradigms. And I think having this conversation about a decade ago would have been really hard because most of the payment models were still focused on fee-for-service model. I think this is the perfect timing to bring these two specialties together because they can hone into the value-based contracting with the payers, and they can be really innovative healthcare delivery, value-based contracts done with the insurance companies, and both Medicare and the commercials are open to having those conversations. And I think this is the right time to bring the emerging speciality of cancer rehabilitation, which is in its infancy, and the cancer pain management, which is a dying art, and almost do an arranged marriage of them and make a baby Yoda and hopefully have a sustainable and a much more comprehensive way of addressing this issue through these structures. So with that, I think we're gonna close the presentation and open the floor to questions. Go ahead. Hi, I'm Brian McMichael. Hello. It's on, okay. I'm Brian McMichael. I'm from University of Michigan. I'm double boarded in hospice and palliative medicine at PMNR. And the problem that I'm seeing are patients, and this is two academic medical centers. I just came from OSU. And the palliative care services, when patients are moving out of surveillance and they've met their five-year mark, are being discharged from palliative care into, like literally they're being handed a sheet of lists of chronic pain clinics. And it's like, go find your chronic pain care. And it's not working out well. They're really, you know, they basically were treated like they're gonna die of cancer. And so the palliative model is to be opioid heavy. And here they are on high, you know, MME. And they're basically kind of being abandoned. So they're chronic pain patients. They were created by the system. But, you know, I don't, my sense is that not many of these are gonna be amenable to interventional pain procedures. But somebody needs to take care of these patients. Is the model you're presenting gonna be able to pick up? Because they're leaving the cancer centers. So in terms of like value-based care, that's gonna have to be the system system and not the cancer center system. I just see these patients like falling through the cracks. That's a great question. Yeah, so that's where I'm at. So, hello. So this is where I think actually coordination with the cancer centers ahead of time, if they saw the PMNR doctor earlier on in their treatment, if they make it to that five-year mark, that makes it a lot easier to transition to the PMNR pain care model, number one. Number two, as Dr. Akalia talked about, you know, there's really good evidence for intrathecal therapy. And then those patients can be titrated down very acutely. Right, so maybe they make it and they're on 300 morphine milliequivalents, let's say. Put a pump in, you titrate them down 5% every three weeks. They have probably, I mean, from what I've seen clinically in some animal models and biological studies, you know, once they've been on that much opiate for a long time, they're never gonna be free of it. But you can titrate them down. And I would argue that once you titrate them down, a pain source may be elucidated from treatment, whether it's peripheral neuropathy or post-surgical or whatever, and then you can actually, can intervene. Now, it might take six months. It takes a much more longitudinal view of the patient, which I think PMNR doctors, I mean, obviously I'm talking in my book, we're all in the club, so to speak. You know, I think if you think longitudinally about these patients, you can have success, but it's not, but to your point, once they get discharged from palliative care, you're not gonna fix it in a week or a month. It's gonna take a while. But that's okay, because, I mean, PMNR doctors excelled the long game, right? So I think, but to your point, so I have a palliative care guy next door at our hospital that I met through not a cancer patient, through end of life from cardiovascular disease, and now he calls me all the time about questions, whether he wants me to bounce something off me or send me a patient. So it's also a capacity issue, right? So most of the private practice guys like myself, even though I'm hospital-based, we're at capacity, right? So we can't absorb a lot more cancer patients, but with the right planning and training, we can open up the possibility to this kind of treatment. That's a great question. I would like to build up on that, and I would ask a question to Dr. Salino. Can we make a business case to the CEO of that health system, through this cancer pain rehab model, we can actually retain those patients within the health system, as opposed to leaking out into the community? So, great question. Much harder to predict out costs and revenue five years out. I think that's a good argument to make, that all right, if we do a good job, five years from now after survivorship, we're gonna have to take care of these patients too, and we can take care of these patients safer. But I think the early business model isn't gonna include that. It's all gonna be about the holy grail of getting patients out of the hospital faster, and preventing comorbidities while they're in the hospital. Thank you. Hi, good morning. I'm Anne Gohong, I'm from MD Anderson Cancer Center, so I'm a cancer rehab physician there. And I did fellowship in 2012 to 2013, and so we've graduated 28 cancer rehab fellows over the years, and probably one of them has done a pain fellowship to enhance his skillset. So he does EMGs, pain procedures, and does cancer rehab. But I think largely the challenge here is getting buy-in in terms of wanting to do interventional pain procedures, and incorporating what we do in cancer rehab too. It's a challenge, because even the pain fellows at our institution come and rotate with us. And largely there's not a lot of interest in enhancing their cancer rehab skills. So I think the buy-in on both sides in terms of trying to enhance interventional pain fellowships to include cancer pain I think is a good potential approach. But I think trying to develop a fellowship would be a little bit challenging in itself to a completely new fellowship. Thank you, thank you for that comment. And thank you for progressing the field of cancer rehab. Oh, go ahead. Well, I was just gonna say, the interest in sticking needles in people, and let's face it, that's why we get up in the morning. And it is, and just speaking for myself. And interest in helping patients with cancer, yeah, it's probably a rare intersection, which is why you maybe need a team, right? So you need the interventionalist with cancer training, but then you maybe need a dedicated cancer rehab doctor too. So I think that's why I was speaking about the team structure, because you're probably not gonna be a single individual, yeah. Hi, good morning, thank you for your talk. I'm Erin Kelly, I am a PM&R and palliative care physician at Thomas Jefferson in Philadelphia. So I am embedded within palliative care, but taking on the cancer rehab patients. So anyone that's funneled through palliative that may have rehab needs, nurse practitioners and physicians are sending to me. So I've had their model of their nurse that's on board, APPs, and then oncology can now refer also the same way. So just, I like these ideas of sharing. But my actual question is trying to build maybe an intrathecal program that is not a pump. I don't do interventions working with fellow colleagues. So I've seen patients that aren't going to have the prognosis to beyond three to six months, but would benefit from intrathecal delivery. So curious if you can comment if anyone's done this where you're doing external epidural catheters or you're tunneling them and kind of what that process was. And if it's gonna take too long, happy to stay after. Don't wanna take away from any others. Yeah, that's a great question. And I can definitely share the experience with what we're in Rochester. So we, again, a team is really important in this, right? So prognosis is important in choosing the target of drug delivery, especially programmable pump. But in patients who have prognosis of less than six months, obviously, from all the different reasons, an implanted programmable pump may not be the right choice. So you can do a tunneled epidural with an external pump, but you need a good team. You need a team of home care nursing, make sure that the other aspects of refill and having the medication available is in place. There is also an option of actually, we did a lot of like port-a-cats. So the same catheter which goes into the veins for delivering the central venous system, we actually use the same catheter in the epidural space. So patients could actually access the metaport and have access to that as well. So a lot of different opportunities to kind of offer that therapy to patients in that small window. Hi, Chris Custodio. I do cancer rehab at Memorial Sloan Kettering Cancer Center in New York. First off, thank you for a very thought-provoking discussion and thank you for taking care of this underserved and very complex patient population for all of you. My question is, what do you think the bandwidth of interest is for someone going into a cancer pain rehabilitation specialty? Like what percentage of the pain fellows are actually interested in taking care of cancer patients primarily? And then within that sub-specialty, what percentage of the PM&R pain fellows are interested in taking care of that? Because as part of our institution, we're affiliated with a Tri-Institute Pain Fellowship, Memorial Sloan Kettering Hospital for Special Surgery in Cornell. And as part of their rehab exposure, they were required to do a PM&R rotation, which we were housed. So they did two months of PM&R within that. We did that for about six, seven years. And the feedback from the pain fellows were they got too much cancer rehab exposure and not enough general rehab exposure. So that pain rotation kind of fell by the wayside. So I was wondering if you could comment on that. Dr. Singh, you want to take that question? I mean, I think in general, the majority of folks who are going to go into the interventional space are unlikely to take all the extra effort that it does require to link up with oncologists, radiation oncologists, you know, physiatrists specifically hubbed within, you know, cancer management. So the numbers are going to be very low. At least where you are in a tri-institute, you've got a chance, right? Like our other colleagues at MD Anderson, she's got a chance because you do have multiple fellows coming through every single year. I can't speak for those who are anesthesia trained that go into intervention. They probably get very little, if not zero exposure into cancer rehab. But on the physiatry side of it, unfortunately it's going to be fairly low. Those who are in these embedded institutions have more of an academic sort of affiliation. I think you've got certainly a better chance and it might just take you going out and reaching out to them to say, hey, you know, from that perspective. Yeah, thank you for that answer. So cancer pain is a dying art. So I think we are at the end of our hour. We'll definitely take questions. All the faculty is here, but we'll end the session dot at 10.30. Thank you. Can I just say, I'm going to put cards at the front for the foundation. There is a cancer research award for the foundation. Right now there's a matching fund in honor of Gail, Gail? Gamble, thank you. My mind just went blank. Who's in my era, who's done some great work. So I'm going to put them on the desk just so if people want to donate.

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