So, it looks like we hit 50 in the room, so we'll probably get going now for the sake of time. Welcome, everybody. This is Day 2 of our Cancer Rehabilitation Community Session. Thank you for everyone for joining and for the people that came on Sunday. Thanks to you for coming back. For the people that weren't necessarily aware of the format, we're trying a little something different more so than we've done in other years. And so, we are, in essence, doing the Great Cancer Rehabilitation Debates in honor of the election year. And next slide, please, Brian. And so, Sunday, we focused on inpatient rehab and the value of cancer rehabilitation. Today, we'll be focusing on cancer prehabilitation as well as interventional options for cancer patients. And then, obviously, wrap it up and then hopefully lead into a great further week of presentations for our conference. Next slide, please. I'm going to remind everyone, if you are not one of the presenters and you're just watching, if you want to hide your video, that will kind of – you'll still be able to see everything. You'll be able to hide and get the best visual format. And next slide. At last year's annual assembly, we've talked about – there was a lot of discussions. And based off this, we, as I mentioned before, we focused on this debate format, which clearly there's still a lot of debating going on in and outside of our field. So, let's move on. Next slide. And so, to start off, to gauge everyone in the room, we'll be starting off with this format, which each side is presenting their points and answers questions from the audiences as well as Dr. Gupta and I, who will be moderating this debate. Our first cancer prehabilitation debate will be – and, Brian, we can click through to the intro, everybody – Dr. Jennifer Behme, Dr. Ang-Kuo Wong, Dr. Andre Chaville, and Dr. Leslie Begay. And if we go to the next slide, Dr. Behme and Dr. Ang-Kuo Wong have no – the disclosure as per their – next slide. And the first part, we are looking to present the evidence for a cancer prehabilitation in an entertaining format. And we'll be starting with the first question of, is there quality evidence for the implementation of prehab? And we can switch. There we go. Next slide. DJ is getting ready to prepare our music. Pre-op is a process on the cancer journey. It occurs before treatment for breast cancer patients. They have improved impairments, physical, mental, and emotional needs. A colorectal patient's hitting the bike. Both on her body, exercise, nutrition, and the process. It's called an incisive colorectal procedure. Call it what you call it. I want to get credit. It's open. I wrote the definition. Hopefully you read it. There's some rehabilitation. Pre-op's emptied. Now we've got nearly 700 patients. Oh, let's go recording. Over tenfold increase in fewer years than that. Pre-op may be cheaper. You have to do it with me. You can come to me at MD Anderson and a super nice successful human pre-op. It even works on Texas fries. I'm going to test her how they decided to do it tonight. Higher CPAP, faster walk. Better PFTs, higher albumin. More likely to be offered surgery and the better shape you're in. What about survival? That would be really good. Enhancing those capacities you have is understood. I wish my dad had pre-opped me with cancer. I will not. Will that really stone me? Sacrum not a weight-bearing bone. Missing so much exercise I was shoveling the driveway alone. I know you can exercise with a diagnosis of cancer. I started with the shoulder. That's what I know best. Exercising. If you don't know, now you know. Cancer rehab. Over to you, Ann. Rehab is a process on the cancer journey before treatment for breast, pancreas, or kidneys. We have improved impairments, physical and psych, in the UK colorectal patients. Hitting a bike. In 2018, the Rehab Society, we went international. How did it get that far? If it doesn't work so well. In Toronto, the great professor, is better than all alone. Don't forget the godfather, Franco Carli of Montreal, started it all. Anesthesiologist in the exercise game. Stephanie Bodo, bringing the healing on the world. For breast and pre-heparal pelvic cancer, BMT and moving forward. Rehab includes other things. Diabetes. Taking a rampage. Decreasing pre-op sugar. It's so easy. Dr. Mir Emanella, showed improvement. That's why I'm actually here. In colorectal cancer, stage 3. How about continence? Would you like to have it? I'm going to show you how to do it. Rehab includes continence. From a meta-analysis. Quantitative analysis of abdominal surgery. Post-operative pulmonary complications. For both me and you. Reduce post-operative pulmonary complications. Robust data. For the elderly. Home-based exercise. Patient adherence to exercise. Heart. Cardiovascular. Cardiac surgery. The literature doesn't lie. So many scientists can't be wrong. Rehab is better than a song. We will move forward to hear the response from Team 2. Okay, welcome everyone to Jeopardy. So today we have questions in the topic areas of Tools of the Trade, Days of the Week, Things That Start With the Letter P, Things I Love About EMR, and Alternative Career Pathways. Andrea, you're our first contestant. Where would you like to start? Leslie, I think I'll take Things That Start With the Letter P for 100. And please mute if you're not speaking. There's an echo. Area of PM&R which could include potentially all of the following. Exercise, nutrition, smoking cessation, spa therapy, relaxation and mindfulness, spirituality and symptom management. That would definitely be prehab because it lacks a taxonomy or specific definition. Because there's an ad hoc non-systematic Chinese menu approach that predominates effectively a smorgasbord of candidate components. We have scant evidence to clarify the relative contributions of these resource intensive treatments in different populations. We have virtually no evidence about the patient centricity of these approaches. It's not clear how to combine components to achieve synergisms or even how to balance the benefit without overtaxing and stressing patients. I think this partly explains the mixed and inconclusive results from a majority of systematic reviews with a few exceptions and meta-analyses in part because it's a bit like the Tower of Babel. We're all talking about different things, anything goes, and that is highly problematic for payers. Leslie, next slide. What would you like to start with? Thank you, Andrea. I would like to start with things that start with the letter P for 200. Excellent. For 200, this P varies in how it is applied to prehabilitation research. That would be what is or what are protocols. Excellent. There are many protocols out there, as Andrea alluded to, and a couple systematic reviews, but there's no consistency across the studies as far as what the experimental designs are, the time points for the studies, or how they're carried out in general. Or the outcomes. Oh, sorry? That was me. I said or the outcomes. Oh, yes, and the outcomes. For example, in the International Journal of Rehab Research in 2018 related to upper extremity function for breast cancer patients, it was a systematic review of all the articles that they found, and this was relatively recent. There were only two randomized control trials, and only one was prospective, and a third one was a prospective study. But between the two randomized control trials, for example, one looked at 30 female patients. They did outpatient physical therapy three times a week, pre-op for one to two weeks, and looked at outcomes at one month post-operative, where both groups but the experimental group had increased range of motion versus the control group that just had educational pamphlet. Now, the other study looked at in-person pre-operative exercise education with a pamphlet and a home exercise program versus the control group just received the educational pamphlet. So you can already see a lot of variability in just this one, these only two randomized control trial studies and the protocols that they did. And the outcomes for this one looked at range of motion at two weeks and six months follow up. Both studies, however, were not concealed with the randomization. They were not blinded. And so, you know, this supports the argument that even though prehab may be enjoyable for a lot of patients, that there really isn't a lot of quality evidence out there to support it. Thank you, Leslie. Okay, next slide, please. Next question. Yeah, next question. I think we'll go on to our second question for our two groups. Should prehabilitation be led by a physiatrist? So I was told I'd have the chance to rebut, so I'd like to do that first. Okay, okay. I'd like to draw Dr. Shaville's attention to the American Journal of PM and article that I wrote with Julie Silver that defines cancer prehabilitation. But I also have here 10 articles that share the same author. And that author is a famous cancer rehabilitation doctor named Dr. Andrea Shaville. I'd like to read you some quotes. So from Toward a National Initiative in Cancer Rehabilitation, this was in archives in 2016. Don't listen to her. What are you doing? This should be offered pre-treatment to optimize tolerance to surgical intervention and adjuvant treatment in order to minimize toxicity and improve outcomes. I also have a figure. This is from Cancer 2012, a prospective model of care for breast cancer rehabilitation. Campbell, Pusek, Zucker. I think he might be on this too. McNeely, Binkley, Shaville, Harwood. Greater pre-diagnosis physical activity and physical activity maintained post-treatment are associated with better quality of life and function post-treatment. A breast cancer-specific tool that includes health-related quality of life and function may be the most effective measure for surveillance of function and the impact of function on health-related quality of life from the pre-operative to the early post-operative phase. So is anything done? No, I don't. So I think, actually, you're making my point. So does this mean that anything that's done prior to anything in the cancer sequence is prehab and should be done? Prior to chemo, prior to radiation, or prior to surgery. Okay. So that becomes almost impossible to accrue a compelling evidence base around. And I think one of the challenges is this idea that anything that happens, if I tell you to go out and get a yoga video, if I tell you to eat more protein, that's prehab, and we need to do that. And if that's the case, then it's really not something a physiatrist needs to do, which kind of brings us to our second question. Right. Let's move on. So let's get to the second question. And in that rebuttal, we'll hear Jen and Anne's rebuttal to that statement that you just posed. So once again, the second question is, should prehabilitation be led by a physiatrist? Yes. And it depends on what context. I think the big debate here is, in what context are we, what is the patient population you're looking at? What are your goals in achieving in prehab? So we think that if you define what you're preparing the patient for, whether you're preparing the patient for surgery, whether you're preparing the patient for radiation, we need to define that time point we're preparing the patient for, and then defining what are our metrics and outcome measures. So yes, the outcome measures are very variable, depending on what you're looking at. Some studies are looking at fitness. Our surgical colleagues are looking at, can you help improve the patient's fitness or treatment tolerance for their upcoming treatment? And so in those type of cases and those type of studies, people are looking at the six-minute walk test. They're looking at leg strength with the sit-to-stand test or the chair-stand test, grip strength, gait speed. And I think this is, if you're looking at what we can do as physiatrists, we can speak a common knowledge with our colleagues in the oncology world in terms of looking at some of these physical function measures. And then you can look at quality of life. So outcome measures that are patient-centric, so quality of life measures. So do you improve fatigue? Do you improve their mood scores in looking at the HAD score and all that? So those are frequently used in some of the prehab measures. In clinical practice, I think it's very important, I think, to try to target what type of patient population you want referred to. So if you want to run a prehab program for a stem cell transplant or a CAR T-cell therapy patient, so you have to know your patient population who's referring to you and what you'd like to have measured as how these patients will improve. So again, our medical oncologists oftentimes are asking for the same things. Can you help improve their function in preparing for their treatments? And what type of metrics? Again, functional scores, FIMS scores may not be as sensitive because these patients are usually at a supervised, modified, independent level. But you can look at AMPAC scores. It can be used also to look at the outpatient mobility score for AMPAC can be used. PROMIS scores, we use that in our clinic. Jen, anything to add? I could talk for another 15 minutes on this. Well, let's go ahead and move back over to the slides, and we can hear Andrea and Leslie's piece. And if we have a minute or so left over, you guys can do your rebuttal at that point. Okay? So if we can get back to slides. Okay. Thank you, Ekta. So Andrea, you're up. What would you like to choose? I will go with things that start with the letter P for 400. For 300? Oh, for 300, yes. Yes. Great. Thank you. Next slide. Okay. The definitive leader of prehab, or are they? Well, you know, some would say physiatrist. But really, if you look at the folks that are publishing the high-quality literature, they're pulmonologists, psychologists, and consultants or attendants that staff the preoperative evaluation clinic, so the POs, or the anesthesiologists. And in some ways, these folks are better positioned because they're already integral to the workflows, preoperative workflows, and often patients are systematically evaluated by these individuals and in these venues. Historically, physiatrists really have not been positioned on that pathway. Their workforce issues, their PO clinics are pretty much ubiquitously established at most institutions throughout the country, and that's simply not true of physiatrists. Certainly in the NCI-affiliated, the quaternary, the tertiary cancer centers, but especially in the community centers, we don't have a workforce that can staff and provide, if we're proposing that, which we actually haven't because we haven't drawn that line. This harkens back to evidence. Who benefits? We honestly don't know. And those criteria, so there were some mention about measures, candidate measures in the prior response, and actually the MPAC, it's the MPAC scores, the mobility that have been showed to be somewhat responsive in later stage cancer. And in many ways, we don't know the responsiveness of the common prompts that are out there to significant delta in physical performance, and that's yet another problematic knowledge gap. The other piece I think that's important to bear in mind as we try and establish a role for physiatry in this arena is the fact that you have statistical significance, clinical significance, and what matters to payer and policymakers, and they can be radically different. And CMS has shown us again and again that they will not pay to change a six-minute walk score. They will not pay for one more sit to stand. And so I think it's really important that we ground ourselves with brutal realism in the fact that any if we're going to improve our patients through these interventions, we need to be mindful of what historically and these are, this is not speculative, there's there's robust and ample precedent to demonstrate what most payers are willing to reimburse. Next slide. Can we go back to the Jeopardy board. Well, I think, Andrea, that will lead us into our last question as right. You're right, we move this into the final and third. Okay, Leslie, sorry about that. We had one more, but it's okay. Right now, okay, we can skip. Yeah, you bring us home. Yeah. So the really last question is can rehab our prehab be implemented as a cost cost effective program given what you just talked about the limited reimbursement. And so I think we'll start with team one, our wrapping team to go and that will lead you guys back into your your your last slide to finish up with our Jeopardy format. And so I'd like to hear from the wrapping team. It depends on how good you are at creative problem solving. For example, I'm in an academic medical center, we get med students for free. So I teach the med students the exercises, they go to oncology clinic and teach the patients, the patients get the exercises at their multidisciplinary cancer evaluation. So they don't have to go anywhere and they don't have to spend any money. Just to go back to what we were what team two was saying about we're not a significant proportion of the literature. Well, my argument would be we're not a significant proportion of the cancer rehabilitation literature. So should we stop trying? So I'd like to share with you a PubMed search. If you search cancer rehabilitation on PubMed yesterday, you get nearly 36,000 results. If you search medical oncology and cancer rehabilitation, you get 3,249 results. If you search physiatry and cancer rehabilitation, you get 3680 results. If you search physical therapy and cancer rehabilitation, you get 10,368 results. If you search surgery and cancer rehabilitation, you get 16,377 results. Just because this is difficult, I don't think we should stop trying. But we can add RCT, systematic review, and meta-analysis to those searches and it's going to look a lot different. Can we have our Jeopardy board? Sam? Brian, if we can switch back to the screen. Next slide. Maybe the next one. Keep going. We skipped a... Keep going. Okay. Leslie, what would you like? Thank you, Andrea. I'd like to start with things that start with the letter P for $500. Excellent. It's the Daily Double. Prehab services may or may not end up turning this for an institution. Thank you, Andrea. So I think Jen actually segued into this question nicely for us and even said, you know, there really isn't or aren't any publications that are showing that prehabilitation is turning a profit for hospital systems or is cost effective given the limited reimbursement. So for example, you know, Andrea was talking about, you know, appropriate studies and randomized control trials to be done. In the Journal of Bone and Joint Surgery, they looked at total hip and total knee replacement surgeries. And they did find in those patients that did physical therapy preoperatively that they had an estimated $1,200 cost savings for their hospital care. But again, this is specific to a hip and knee, and I think we can all agree that our cancer patients are much more complicated than a joint replacement. There are some lung cancer studies that have shown decreased length of stay during the hospital for the surgery, and that could be interpreted as having decreased cost for the hospital system and for the patient. However, these studies haven't looked longer term. What are the other costs that the patient is incurring after they've been discharged to home for their follow-up care, for ongoing rehab needs as they undergo chemotherapy or radiation? And so these studies haven't been done. There are two studies that I found, one in 2019 and one in 2020, that published articles about multimodal prehab programs, one for lung cancer patients, moderate to high risk, and one for colorectal cancer patients. But these were just publications of protocols. There aren't actually results published yet to show that there's a cost savings or cost effectiveness for these patients. Andrea, do you want to add anything to that? I think you did beautifully, and they're just about to pull us off the stage. Let's move back to our presenter slide, as I think Andrea and Leslie are giving thanks to Alex. Better head of hair than I ever had. But let's give a chance for the opposing team to add in, and then we can, Dr. Grupda, can guide through further questions for our discussion time. This is a great topic. I want to make sure we leave some time for further discussion to build off of the questions. Damon, no, 2024. Just kidding. I think there's some places we can agree. Franco Carli out of Montreal has a multi-country study going on to look at cost because it's an important issue. One place where they can actually do that pretty well is the Netherlands. They're actually doing a study there to assess carefully the cost of prehab and look at it for a benefit. I anxiously await those results in maybe 2024, hopefully before then. I think the challenge here is a lot of these multi-component, multi-modal studies, it's hard for us to pinpoint what is the most valuable or what is the most effective part of prehab so that we could prioritize one or the other. That's the big challenge. A lot of the institutions, I think, are using this enhanced recovery model. We are definitely using it at Anderson where you're standardizing the protocol of patient care preoperatively, perioperatively. There's so many components. It's the pain management part. It's the physical exercise part. It's the nutrition part. It's managing the mood symptoms and going into the immediate perioperative period. The anesthesiologists are changing up what they're doing for patients, too. It's hard. I think we've, internal here at the institution, have tried to look at cost savings, too, and changes between pre-ERAS, pre-prehab versus currently with our current enhanced recovery programs. It's hard to say, okay, well, does the prehab part help with the cost savings or is it just this entire enhanced recovery model that we're doing? We're doing enhanced recovery for transplant patients, stem cell transplant patients. Before even starting, at the beginning of starting this program, we've been looking at cost. How much does it cost for an allogeneic transplant patient to undergo transplant at our institution where we have this prehab enhanced recovery stem cell model? We're three years into it, and we'll be looking at the cost of that, too, and see if there's any significant difference. I think, theoretically, a lot of buyers like it. We've actually held insurance symposiums at our institution where we invited big payers, Aetna, Blue Cross Blue Shield, Medicaid of Texas, a whole band, and we ran a whole day, two-day conference for the payers. A lot of them stood up, and they were like, prehab, what? I gave a talk on prehab. They're like, what is this? They said, if someone denies prehab, please get to your medical director and talk to them and explain what you're doing with prehab, and we're not going to deny it. That's just anecdotally with what we're doing here. One of the things that concerns me, and we can look at what happened with injections, that teeing up our next presentation. Medicare got very smart and said, you can't bill ultrasound separately. We're going to bundle those. People were nickeling and diming CMS, so you'd bill for it, and it was a lot more money. I think we have to be very watchful of that. You're right about multi-component interventions, but there are methodologies. Actually, Hassan Murad has written quite a bit about meta-analytic and systematic review approaches to try and identifying those synergisms, because this is a common problem. Interestingly, they work better. There's now, for complex, high-dimensional, and what you're describing is high-dimensional data. There's a heterogeneity of demographic and clinical characteristics, the procedures, complications, on and on. This is where AI may actually have quite a bit of utility, if we are able to begin systematically collecting that information and creating high-quality curated datasets. That's ultimately what it may take. Apologies for being a stickler about definition, but if we try and make this all things to all people, payers will balk, it won't just be MD Anderson with a very codified and perhaps protocolized approach. What we've seen in the past is where there's money, there tends to be a lack of restraint in healthcare, and things are overbilled. It's not a hard stop, no, but I think it's a cautionary tale, and one that we need to be sure we have our ducks in a row with respect to high-quality, perspective data collection to be able to respond to payers when these are overutilized. Trust me, they will be. There has not been an exception. When something lucrative is overcoded and overbilled, payers respond. We are sitting at ivory towers. That's not their major concern. Currently, SNFs are making their average profit margin is 27%. Those are the private SNFs. That's what gives CMS pause. It's not the MD Andersons. It's not the University of Massachusetts. It's the for-profit centers that are just milking this. It kind of leads into a couple of our audience questions, actually. Going off of what Andrea just mentioned, Sean asked that question, outside of MD Anderson, what PM&R programs have a robust prehab program, and how is this implemented in these institutions? Kat kind of went ahead and asked a very similar question, which is, if you're interested in even starting a program, where would you advise somebody to start with? Where do you think the buy-in is? Then we can hopefully get to Lynn's question right after that. I like the stash question. There's stash cotton. Nobody rocks a stash like Trebek. I think Anne is actually training some people. Do you want to take this one, Anne? Your trainees that are interested in starting programs? Yes. I always tell our fellows that they come here for a year-long education, and they take away what they need into their practice. A lot of what we do right at the beginning of fellowship is, what kind of practice are you looking into going to? What kind of work are you looking into going to? Are you academic? Are you private practice? I've had a lot of trainees during their year ask about, how do I start a prehab program? I've had people go and start their work and then come back to us and say, hey, what do I do? That goes to the question of, where do you start? Like I mentioned earlier, you find one or two oncology or surgical oncology colleagues who are interested and really invested, because those are the people who are going to help you support the program and help advocate for resources for you. It's hard to say patients with esophageal cancer are in greatest need, or bladder cancer patients, or patients with pancreatic cancer. It's challenging. It's hard because the studies in these groups are quite variable too. I think finding an advocate and finding a group with great need is very important initially, so you can demonstrate the potential for improvement for these patients also. Historically, we always fall back on diagnostic bins and diagnostic categorization, which is very easy to do in cancer. However, if you look at paradigms and frailty, where there's been a lot more of this work done, that's not what they're doing. It's based on a constellation, sarcopenia, cachexia, serologic markers, biomarkers. Maybe, are you doing any of that, sort of metabolomic characterization of these populations to figure out not just... Because honestly, cancer type is pretty crude. There's a lot of heterogeneity within that. Cancer type may not be very relevant at all, ultimately, to who benefits from prehab. If we step back and start thinking about what should be the candidate criteria that we systematically assess to really determine who benefits. We're working with our geriatricians here at the institution and looking because our patients are referred to them, and they ask us, well, who are the best candidates to send to you for prehab when we see some of these patients with the geriatric assessment are found to have certain risk factors? And so, I agree in terms of trying to find patients with the physiologic millow who they need this, that they're at risk for significant decline during treatment, and who do we target? So, that's one way to go about it. Also, is to look for patients who are frail or high risk or sarcopenic or high risk for deconditioning. I think at other centers, most centers, I think the surgical oncologists are seeing different diagnoses. So, you're sitting with your surgical oncologist and you're asking them, who are the patients that you have trouble discharging after surgery? And why are you having trouble discharging them after surgery? And I think using that kind of like a landing point in terms of stepping stone for the discussions of the goals of starting prehabilitation for some of their patients. Actually, Brian asked a great question. Well, hang on, please call me Andrea. Wouldn't that just make it more expensive? You're talking about ratcheting up. I don't think so, because a lot of these markers are collected anyway. Has anyone heard of this? There's a study. Actually, it was in our wrap. So, reference number 11, I can tweet out or send out the references. Jennifer Ligabel at Dana-Farber, who's a medical oncologist. And so, my concern is, yeah, we can wait to find cost data. We can wait for all these randomized control trials. But they're being done by anesthesiology. They're being done by medical oncology. What are we waiting for? We're the exercise experts and anesthesiologists in the United Kingdom have the majority of this research. So, it was in clinical research. Does anybody have a trial going on in prehab? He finished and published this trial with biomarkers. So, one was gene markers and how exercise before surgical intervention in breast cancer changed genetic markers. And one was biomarkers in the blood that she was able to measure before and after exercise prior to surgery in Boston. We actually are running a trial right now with pancreas patients. We have 132 out of 152 patients randomized trial of usual care versus exercise, moderate intensity exercise for patients. And we're looking at six-minute walk test, but we're also looking at tumor vascular changes. So, we have a cancer biologist in our group who's looking at tumor vascular changes. And the theory is a moderate intensity exercise can improve vascular changes in the pancreatic tumor, improving uptake of the chemotherapy. So, we are looking at tumor markers of vascular changes in the tumor. Yeah, I think it's fine to say let's forge ahead. But if in parallel, you are conducting research to scrutinize what you do, I don't think it's okay. And I think most of us would agree to be exhortative and say we must, we must, and ignore deficits and not be contributing, actively contributing to evidence. The deficits are within our literature. They're not in the anesthesia literature. They're not in the medical oncology literature. There are studies out there being done by other disciplines. I just think we should have a seat at the table. There are over 700 articles on prehabilitation on PubMed. Right now. Okay. But I guess I think if we're going to push, we need to make sure the way you get, in general, the way you get credibility and a seat by being perceived as a value add, and through publication, by contributing to the evidence base. And so, I think it's vital if we're going to be exhortative, which is fine. We also need to be, in a very concerted way, setting ourselves for high-quality observational studies and RCTs, because they still are the coin of the realm. Agreed. I think those are actually really great points. This is a fabulous discussion. We are getting close to our break time before we start on the next section. I know there were some other questions that were posed, and there's a really great discussion going on in the chat, too. I think we'd all love to hear the responses. If our discussion panelists get a chance, if they can just respond to some of the chats. If we go back to our presentation, and thank you, once again, all four of you. That was really great, really entertaining, above and beyond, and we really appreciate it. They set the bar high. We were very intimidated by the wrap. Well, both were wonderful. The Jeopardy tie-in was really a great tribute. Thank you, all four of you. If we just take a short break, so it is 1.43. Sorry, we keep cutting down our breaks every session, but if we can kind of try to aim to be back by 1.46, so if we can do just a three-minute break, and then we have a really exciting discussion coming up next about interventional procedures and injections. Thank you all. Keep the chat going. I'm sure our debaters will respond as they can, too. Thanks, Ekta. Yeah, thank you. Okay. It is 1.47, sorry. If we can go on to our next slide. Welcome back, everybody. I see there's still a robust discussion going on. If you can keep that going, our next debate will be on interventional options for cancer patients. In this debate, we have three questions with five minutes each from the sides with pros and cons to each question. At the end, we will have six minutes for audience questions. Once again, please post your questions in the chat like you've been doing for the last one, and then we'll try to address them as we go on with the debate. Our debaters include Dr. Brian Fricke, Dr. Lynn Gerber, Dr. Kat Powers, and Dr. Megan Clark. If we can go on to the next slide. Our first question will be, what is the evidence behind injections in cancer patients? This may include Botox, steroid to joints, as well as epidural steroid injections. Next slide. I will hand it over to Dr. Gerber and Dr. Fricke. Well, thank you all and thank you Dr. Gupta for that introduction. I'm glad to be able to speak with you guys about this. If we could advance to the next slide, we'll just jump right in. We don't have any disclosures. I apologize because our presentation is probably not going to be as rife with entertainment as the last one was, but we'll do our best. The first question we want to address is what the evidence is behind these injections that we offer for cancer patients, looking specifically at Botox, steroid, and epidural injections. With Botox, there's some evidence that this could be helpful. Physiologically, it seems to make sense. We know that we use botulinum toxus for a number of other painful conditions. There's evidence that shows that it inhibits release of substance P, CGRP, glutamate. It can reduce peripheral and central sensitization, and can be very helpful in specific settings in patients with cancer. Any central involvement of the CNS that could result in spasms, painful muscle spasms, spasticity, as well as improving muscle spasms from cancerous mass lesions in soft tissue. There's also post-op neuropathic pain from surgery and radiation that these have been tried in, as well as post-parotatectomy gustatory hyperhidrosis. This review of the literature showed some improvement in those conditions in botulinum toxin. However, it did acknowledge that there was the proof of efficacy for cancer-related pain as its own entity, is still awaiting blinded placebo-controlled trials. Go to the next slide. The good news is for botulinum toxin, this is generally considered pretty safe, especially when you're combining it with radio chemotherapy and other non-pharmacologic means of intervention for addressing cancer pain. But the efficacy for botulinum toxin in and of itself is still yet to be demonstrated. I included a few studies here to talk about how some of these studies are really not showing much difference when they're compared to placebo. Some of them showed some objective measure improvements in terms of the range of motion that's regained, or the mobility, but not really in quality of life or other patient-reported outcomes. Then one of these studies shows statistical difference in the pain-related outcomes. However, this was not clinically significant within that study. We can move to the next slide. Moving on to peripheral joint injections. These are something that are bread and butter procedures that we do within PM&R as a whole. There's a case series that we found that they did at Sloan Kettering where they looked at a few cancer patients that underwent intra-articular and greater trochanteric ursa injections with steroid buprevacaine. Had pretty good relief, and so that was very encouraging. However, of course, this is only an N of three, so it's hard to generalize a lot of those findings as well. This was not very specific injection because they injected both within the hip joint itself. For this, what they were calling cancer-related hip pain, but also injected along the greater trochanteric ursa. Next slide. Then of course, axial injections. Even within the pain literature as a whole, the evidence is starting to show that it's not very well-founded that these are effective treatments for axial back pain or even radicular pain. There's a lack of evidence for really doing any interventional pain procedures alone. This will lead me into the next section where the name of the game is really interdisciplinary care when treating patients for cancer pain and not injections as standalone interventions to address pain. The evidence does exist for some conditions, but they're again largely case reports or case series, just not really robust enough. Going back to Dr. Shabil's comments, the randomized controlled trial is really the gold standard for what we want to look at and hold up to say these are reliable interventions that can be implemented into guidelines that can be employed on a much grander scale. But with these specific small studies, they're helpful, but really need to work on building the literature out so that we can create these generalizable recommendations. I think that's it for these slides for this section. We'll hand it over to our opponents. Yes, if we can go on to presenter mode. Let's hear our pro side. Yes. Thank you, Dr. Fricke. While you did very correctly justify your case and saying, yes, there's not a lot of evidence, you also helped us in establishing safety on a couple of those, which I find very helpful. Ultimately, Dr. Fricke is absolutely correct. The evidence that we have is not strong specifically to cancer population. However, if we think about a lot of the things we do, we don't always use literature specific to cancer patients. The best example I can think of is for years, we've been treating patients with chemotherapy-induced neuropathy with an assortment of neuropathic pain medications. But if you look at the literature in the past, say 20 years, not until recently have we looked at chemotherapy-specific neuropathy. We were using literature based on the presumption that it behaves the same way as diabetic polyneuropathy. But we had some good results and we went along with it because we knew ultimately a lot of our patients had an improvement in their symptoms. For us, we obviously want improvement in their pain and their function. We use that strategy and it was quite successful. Plus, we knew about safety because this is something that we do in our regular practice. Yes, limited evidence, but for the most part safe. I think through the next few years, decades, hopefully cancer rehab will establish ourselves and be able to do more studies proving the effect of these interventions and we will be part of that and hopefully able to gauge the trials so that we know exactly what to look for. But we know objectively in the patients that we've treated ourselves, they report symptom relief, they report improvement in their function, so we feel comfortable doing it. I'm going to pass it off to my counterpart to help us sail home our arguments. Yeah. Not that we need a lot of help in selling it. I think the arguments are correct. We need more research in the patient-specific population we're dealing with. Like you said, Botox has its uses, and I'm sure for a lot of us that are on this right now, we use it clinically for a variety of reasons. Like you had mentioned in through there, for cancer-related pain, for that particular, there are limited uses for botulinum toxin or limited evidence that it's clinically beneficial. There are a lot of other new uses that are coming around with botulinum toxin though, and research that's coming in from GYN and prostate to tumor genesis options that are possible with it. Obviously, we use it for some of the cranial nerve palsies, and there have been a couple of studies like sick cranial nerve palsies that we're using it for. Even a couple of studies I've seen intralesional injections, does it help with chemo delivery options with that? I think that there are potentials, botulinum in particular, there are potentials that we're looking at even outside of our general just cancer-related pain symptoms. Obviously, I think steroids are a tricky situation because even for me as a needle jockey who loves sticking needles in people for different reasons, I'm real hesitant with steroids in general because we are seeing more and more that it's not a great long-term option. It's not something we want to do repeatedly. I have trouble sticking them in joints just in general. But for us as a service to be able to provide to these patients to get them started in that multidisciplinary care, to get them started moving and help with that initial pain relief with a little bit quicker symptomatic recovery, sometimes it's a nice one-off option to be able to get them going in that direction. To be able to provide some of that is helpful. I also think through this, being able to provide that symptomatic relief quickly for a patient establishes some pretty quick trust, some pretty quick good relationship for all of the other things. Even some of this prehab stuff that we were talking about and the importance of all of that. Some of the other symptomatic things that the patients then will have faith and talking to you about that you're someone they can rely on that help them through this to be able to provide them with some relief. I think with this question, when we talk about steroids and botulinum toxin in particular, there is some question with that, but I think it leads us nicely into the next question too about what else is there and that there are other options that can be provided with this. Well, thank you for that transition, Dr. Clark. Brian, if we can switch back to our slide view. Next slide. That will, as Dr. Clark mentioned, lead us to our next question of what are our other options and are they just as effective? I will leave that back to Team 1 to take the lead. Yes. Other options, really, and I appreciate the comments from Dr. Power and Dr. Clark. I think the key there and what I picked out of the comments was really that a lot of the evidence that is out there is really anecdotal, which is useful, but it's hard to generalize those as recommendations for what we should be doing as a specialty and what we should be offering. There may be particular nuances in the training that you guys have that is not generalizable to cancer rehab doctors as a whole, and that can make things very challenging with saying, yes, anytime you go to see a cancer rehab doctor, this is what the expectation should be. Now, something that is a little bit more evidence-based and has literature behind it is medical management. Identifying patients and something that I think we as PMNR doctors, we can all agree are exceptional at is neuromusculoskeletal diagnosis and differentiating patients' pain from, is this cancer-related pain or is this non-cancer-related pain? Look, I added in a few of these tables just to demonstrate the wealth of information that's out there with really emphasizing the guidelines that exist for treating neuropathic pain. They're in the middle with first, second, third-line agents. Examples on the right showing the different aspects of interdisciplinary care. They're integral to holistically treating and managing a patient's pain really of any kind, but especially when it comes to cancer pain. Can we go to the next slide, please? As I mentioned, opioid management is really a mainstay for any patient who has active cancer and especially metastatic disease. It's a great indication for this. There's very strong evidence across the literature and all types of cancer for management of cancer pain and using opioids. There are a number of guidelines that are out there, many written by and were reviewed during our fellowship training at MD Anderson by the palliative care folks who are quite passionate about this. But we as rehab doctors, I think, are also very well-qualified to do complex opioid management on patients, manage their morphine, manage their methadone. These are all great medications that can very appropriately and effectively be implemented into caring for cancer patients with cancer pain. Next slide, please. As of much of what we do, best practices approach is really having an integrated multidisciplinary program, doing physical and medical interventions, partnering with our therapy staff, partnering with behavioral health, pain psychology if that's available, all those specialties to really create a clear and individualized patient management strategy. We really pride ourselves in focusing on what the impairment is and how that's contributing to disability as rehab doctors. Identifying where these patients are having their pain, how it's affecting their function, how long it's been going on, what other conditions are going on contributing to this pain. Most importantly, with these cancer patients who face tremendous amounts of financial toxicity, what are the cost of some of these interventions that we're offering? Next page. You can keep going. I addressed this already just for time's sake. As I mentioned, the interdisciplinary team, in addition to partnering with the therapists, the dream would be to have this multidisciplinary clinic where all of us are working together. Working in the same clinic with the oncologists, the surgical oncologist, the radiation oncologist, to help them identify which patients are appropriate for rehab, that can benefit from our services, both medical management and otherwise. Having an orthotist available there to help with supportive braces to help improve pain control, as well as case management or nursing to really effectively, I think, manage this beyond what the injections would really offer. I think that's it. Thank you. A very comprehensive response. Now, I think we have the opportunity if we switch back to our presenter view of hearing what Dr. Power and Dr. Clark have to say in response. We agree. Teamwork makes the dream work. As physiatrists, we all are experts in that high-level coordination of care aspect, and we want to continue to do that. For us as physiatrists, we also bring a broad toolkit and a set of skills to the table. Procedural skills are one of those things that differentiate us from some of those other team members. The palliative care team member who's on there, the therapist, the dietician, the exercise physiologist, the social worker, what is something that we can do and offer that's unique and separate from that group, and sometimes that is a procedural offering. Like I mentioned before, botulinum toxin and steroids aren't our only procedural offerings that we can give. We learn through our residency, we're provided with those tools and skills to be able to offer some different things, nerve blocks or sympathetic blocks. There are some newer procedures that are coming out, tumor ablation and the STAR procedure for metastatic disease, whether tenotomy even can be helpful for some of our folks that are seeing some of those AI effects. So we get a lot of Achilles tendinopathies and plantar fasciopathies, and some of those things can respond to interventional treatments. So I do agree, and I think that our adjuvant to that multidisciplinary team can sometimes come in the form of procedural and interventional options. Not that we aren't perfectly capable of handling all of it ourselves. And like the discussion before was, in some of these smaller hospitals and community hospitals, are we able to even have a big team like that? So we might be dealing with all of it ourselves too, but it's nice to be able to have that extra skillset to be able to provide to the patient and the healthcare system that really separates us from some of the other team members. I don't know if Dr. Powers has any other. So yeah, I would just add completely on to what my fabulous colleague has to say. We wanna set ourselves apart. We want to create this identity for ourselves. And one of the things that we learn in rehab residency, and if we're lucky enough, a cancer rehab fellowship, are these specific procedures that can be done for this population. Furthermore, the drawbacks of some of the other things that we do offer and are very appropriate for certain patients can possibly be managed with these procedures. So if someone is gonna be on medicine for a very long time, a lot of pills, you're decreasing the pill aversion, and possibly decreasing the systemic effects of pills if they're perhaps susceptible to an injection that might last four months. A lot of these patients are a bit overwhelmed by the amount of medications they take. They feel like skeptical of a lot of them. I mean, there is some distrust in the medical system and that goes to procedures as well, but sometimes they're open to additional options. So it's nice to have an additional option. They may choose not to have a procedure that offers something, but knowing that you can kind of talk about pros and cons of it is really helpful and feeling that you can deliver it safely so that you can, as Dr. Clark mentioned earlier, establish that trust, allow them the opportunity of seeing what you have to offer and perhaps opening the gates, because if you're able to kind of decrease their pain at the one time and then say, hey, Kate, it's great that you're doing well now. Let's send you to therapy so this won't happen again. Let's reduce this risk of having this adhesive capsulitis. We want to get you that range of motion back. And knowing that that's a way that they're coming to us and open to it, it's great. I want more tools, not less. Okay, well, I think that was a great discussion. Oh, Lynn, do you have something to add? I would very much like to weigh in on this excellent conversation and pro-con discussion, which really did outline some major problems, both in terms of the delivery of care to our patients and to the literature. And I would like to address both of those. The literature is, excuse me for saying this, very thin. Certainly of RCTs, Dr. Chaville's comments right on target. But I would challenge this group to think slightly differently. Not only is it thin, but it is driven primarily by impairment outcomes. Impairment outcomes are exceedingly limited when we are dealing with complex chronic illness. And the cancer literature is fraught with that in part, in my view, having done extensive scoping and narrative reviews and reviewing clinical practice guidelines because it's often driven by, and I'm not knocking any of these people, speech language pathologists, surgeons, anesthesiologists, and often it is done to get papers published. The very difficult work of managing and providing good care was outlined in the very first part of the presentation by Dr. Fricke. Not a single intervention works by itself, partly because it addresses a local problem, which is fine to enter as a way of reducing symptoms in order to provide a multidisciplinary and more comprehensive program towards functional outcome, which is our desire, but also because we have not done our own homework to understand which components actually are the active ingredient. We talked about that in the first part of this discussion where we talked about prehab, which aspects of prehab are really producing the outcomes desired. And there we have, just like our field, multisystems, multidimensional outcomes that must be addressed. So I fully support the view that without RCTs, we don't get high levels of evidence. But when our RCTs are driven by impairment outcomes, it is not going to advance our field. So we need to think in a matrix. We need to think in terms of the relative contributions of interventions that we have available. Dr. Clark mentioned our toolbox. Well, clearly it's more than a needle in an anatomical locus. So that's one comment that really has to be fully explored in this discussion. Second of all, it really does seem to me when you start looking in depth at even the case reports or the case-controlled studies, these are directed towards very specific outcomes. The Botox is looking at sialination, how much spit are you able to generate? Well, excuse me, I'm much more interested in whether or not the person can chew and swallow their food. Why is that not a part of the outcome? So the nature of the outcomes are so restrictive. If you look at the use of Botox for pharyngeal esophageal spasm, and there is some, it wouldn't matter a damn, excuse me, I forgot we're on public TV here. It wouldn't matter at all if people were not able to use that treatment to be more articulate and or to be able to swallow liquid solids and semisolids. So we, excuse me, I am proud of our profession. We physiatrists are worried about that. We are not interested in symptom burden reduction for its own sake. Maybe palliative care is, but our job is to identify which symptoms are the most or major contributors to interfering with return to functional outcomes that patients value. And that's the third point I need to make, which I've been asking for the last two sessions. Patients often drive the nature of interventions. We have not yet fully embraced their participation in our research studies. And we also unfortunately focus on the things that we know that we can improve. So we need to expand that horizon so that we include what the patient is going after, how this will impact those functional metrics that are critical and do it for their lifetime because it's not like a knee replacement. Believe me, I live in the arthritis world. It is in fact a multi-system, multi-dimensional biopsychosocial model when you have had a life-threatening diagnosis whose treatments are as threatening as the life diagnosis and whose natural history, unfortunately, we can't always predict. So we have a lot of work to do to reframe the nature of our research activities. And we also need to do some hard work about doing good, effective clinical practice guideline development that's not exclusively dependent upon RCTs because we as a specialty have created a very large amount of information based on empirical data and on good observational work, which need to be incorporated with an under-resourced specialty ahead. Excuse me for standing on my soapbox, but I thought we had to bring in some of these other elements to get you guys thinking and moving the ball down the field. Thank you. Thank you, Lynn. That was wonderful. So well-spoken. I don't even know where to go from there. I know. I can keep your breath up. We do technically have one more question. If we can just try to kind of quickly get through that, if we can go back over to presentation mode. So our third question was, what is the value of injections? Why should we offer it? You know, and I think this will be a pretty quick discussion and then we can open it up to the open forum and kind of post some more questions and hear a little bit more from everybody. So go ahead, Dr. Fricke and Dr. Gerber. Yeah, thank you. And I will keep this very quick. Thank you, Dr. Gerber for those comments. I'm very glad you're on my team. So yeah, as far as reasons why we should be doing this, what value does it add? You know, I think it's really tough to justify if the lack of effectiveness is there, the lack of evidence to support doing this and how it could impact. And as Dr. Gerber pointed out, and I couldn't agree more, the idea that the injections are the special sauce that we have as rehab doctors to, you know, really make improvements in these patients' pain, I think is kind of underselling ourselves to a degree because we're more than, as I think everyone on this call is, more than, you know, needle jockeys, to borrow a term from Dr. Clark. So, you know, I think that botulinum toxins can be very, very expensive, especially when there are patients, especially what I see here in San Antonio, a lot of unfunded or underfunded patients. It can be very, very difficult to get these kinds of interventions for those patients in that population who have just as much need. Next slide. And this is just a few examples, and these are for on-label uses of botulinum toxin for spasticity, bearing in mind that for a number of the conditions that we would potentially be using Botox for, they're really off-label uses of these medications. So, you know, I only hold up Botox as an example, really, because it's an easy example, but a lot of these procedures that we're talking about are adding costs to the patient's already pretty substantial bill for getting their cancer treated, getting their pain controlled comparatively, doing things like medication management, referring them to therapy, which a lot of those studies that I mentioned earlier on used as controls to compare to the intervention or non-intervention, showing similar outcomes, essentially, because there was no real clinical significance to be different, that we have to really ask ourselves, how much value is this really providing to the patient, or is this really providing value to our pockets and helping us, you know, improve our reimbursements, improve our income, and, you know, sustaining a practice of cancer rehab and trying to expand into other areas of care. I think that's all I have. Okay, great. If we can go on, perfect. And then we can just hear from Kat and Megan, and then we'll open it up. So just to kind of pop on that last one, unfortunately, not all insurance companies have the similar kind of ideas about cost and where they're gonna put their money. I've had patients, unfortunately, have way too high co-pays for physical therapy. And so sometimes they will cover the cost of an injection, and then I can give them a really comprehensive home exercise plan and try to guide them through the steps that will lead to a longer lasting result. So, I mean, every person is different. All our patients have unique attributes that we wanna address. And knowing that it's an option, or hopefully is an option for certain patients is huge. As we were discussing earlier, it separates us from several members of the care team. And yeah, it shouldn't be our only, you know, like, oh, look at us, we at least put needles in things. But unfortunately, there still is not a great understanding of what we offer from some of the other practitioners that we may interact with that maybe haven't had as much exposure to people like ourselves and from patients. And so, you know, very simply, if they don't know what we do, you know, even saying to a patient who's like, oh, well, are you a physical therapist? You know, like, it is a very simple and more concrete way of saying, well, this is what they can do, and this is what we can do, that kind of thing. So it's not a great reason, but you know, it's one of the things that we can at least use to kind of highlight. I'm gonna pass over to Dr. Clark, so we still have time to questions. Yeah, and I think Dr. Gerberson set up so well. It's hard to be on the opposing side to someone like Dr. Gerberson. So I definitely, I do agree with everything that you say with it. And I do, it's not, obviously for all of the things and all of the things that we offer, we want to do that comprehensively. It's same thing true with, we want to have that comprehensive team for our patients, because we understand the importance of being able to come at this from a multimodal direction. So, you know, the injections, and even though we kid, we're pro stick-em team, it's just a part of it, or a piece that can be contributed to it. But at the end of the day, we want that piece to still optimize their function, because I completely agree. So what, if it doesn't hurt when I press there anymore, what are you able to do with it? You know, if you're still sitting on the couch when I'm giving you, you know, medication management, if you're sitting on the couch, 23 out of 24 hours of the day, what difference is that making for you, really? So I think, you know, the idea, and hopefully the offerings that we can give as physiatrists can just include some of those procedural skills, even if it's not something that you're doing yourself, just the knowledge of the opportunities that are out there that may be able to contribute to and benefit those patients in their function going forward. May I add onto something? It ties in something that the great professor, Dr. Cheville brought up earlier, which I think is very critical. She's written about this extensively for stage four lung cancer patients who have been referred to rehab and for whom insurance will pay. There is a calculus that we as physiatrists must always consider. It's not just motivation. It's the entire package of illness that the individual is experiencing. That may not be a priority at that time. It also may not be the kind of thing that is likely to help them overcome their fatigue in order to participate. So one of the challenges for us, and it's certainly a challenge in research to try to sort things out in terms of understanding the active ingredient is trying to identify those things that may interfere with participation in rehab or prehab, or in fact, that thing which ultimately doesn't result in a good functional outcome that we may not have addressed at all. So I think we have a very complex series of problems to evaluate and to put in some kind of rank that addresses what the patient needs and wants early on, just as you said, Dr. Clark, to get it going and then to build on that towards patient goals. Okay, wonderful. That was a really great discussion. I still feel like every time Lynn talks, there's like a mic dropping. But I think we had just a couple comments. I think Lynn and Andrea and Mary are talking on the chat as well. I think this is a great idea. David's put in some thoughts and the CRPC is what we make it. We have multiple subgroups in there. And so if this is an idea that somebody wants to pursue, please reach out to all of us. We're happy to continue to push this forward. I think if Lynn has a few moments to elaborate further, Mary posed the question of how do we leverage the observational data? How can we go about that as a group or even individuals in our practices that can then make a difference in the way we are able to put value to what we do? Well, the development of clinical practice guidelines, which is not the same as best practices, is fundamentally evidence-based. In areas in which the evidence is unfortunately not where we would like it to be, ultimately, we are able, using a constituted review panel of people from a variety of backgrounds so that we're not promoting Lynn Gerber's approach or Megan Clark's approach, but we are really identifying the body of information, which may have been gotten from descriptive studies, from mixed methods methodologies, from RCTs, from case reports, et cetera. And putting that together as the best body of evidence that we have, often it's a way forward. It may not be the ultimate goal, but once it's out there as a CPG, you guys, all of us, are on very solid ground because that's where CMS starts the ball rolling. It rarely is going to be informative if it's a single intervention strategy for cancer rehab. So we have to do our homework. It's a big lit review approach, and it's also constituting people who have a mixed background of specialties. And that is one way of leveraging the observational data. You've done the process according to the guidelines. And then once you get the CPGs out there, you're on, you can make a case. Now, Mary asked another question, which is something I also have been thinking about. It is possible for us to look at small studies in which outcomes are very rehab-centric as opposed to impairment-centric. And we could reverse engineer that. In other words, think back as to which elements actually went in to giving a positive rehab outcome. That may start our thinking around different pathways. But I think the first step really is to, let's say lung cancer. Can we come up as a group with a good CPG for this? I remember at the ACRM meetings last week, there was a question on this very issue. So what next step? So take something that's common that we got lots of problems with that we don't have consensus around and see if we as a group of different backgrounds can come up with something that looks like a CPG. Thank you. So definitely we've brought up a lot of interesting ideas, research possibilities. I once again wanna thank our last four debaters. This is really wonderful. We are coming up on the end of our community session time. So we're just going to see Brian's cute dogs. And then we'll go on to a quick conclusion. So as Sam talked about when we opened up this second community session and I had discussed in the first one, we had tried to do this community session as a way to get everybody involved. Kind of with the current political scene, we chose to do a debate, stick to educational topics, topics that we are all interested in. Lots of great research ideas have come about. We also wanted to do a quick networking session next week. We just didn't have time to get it in this week with the virtual format of our conference, which has been really wonderful. So we're gonna post out a Doodle poll link to try to get a time and date that works for everybody. This is open for our whole group, so please participate. And it'll be a good way to hear a little bit more from each of our subgroup leaders, as well as get ideas and hopefully get more involvement from everybody that's here listening to our community session. So we can all make an impact on cancer rehabilitation. I'd like to thank Brian and Grace. They have been really, really helpful in getting this session organized. And then Sam is a wonderful co-chair. He has been really supportive in getting this whole program going. And we also have a lot of wonderful physiatrists from around the nation that have been involved with this session. So thank you all again for joining us. And we'll hopefully see you next week. So I just wanna add in, thank you, Ekta, for leading this. Obviously, it's been a challenging year for everyone. And so obviously the support staff at the AAPMNR, this would have been a lot bigger of a mess if this was up to doctors to try to figure out all this technology. I did post up the copy of the link for the Doodle poll in the chat. We will post it again as everyone's chatting just so we don't have to search for it. We also posted in a few other avenues, including phys forum. So please jump in. It looks like we had over 80 people here during this session so I'm hoping we get more just about in the network session if possible. I think this format is really helpful as we're growing as a specialty and a subspecialty. We need to have these tough conversations to figure out what's the best way to go. We're all not gonna agree, but that's a good thing. We need to have some disagreements to figure out what's the best way to move forward. So hopefully this can stimulate some ideas. And I know I think Dr. Zucker and a few other people commented about how this is helpful about kind of sparking some ideas. We will have to see how COVID in the year goes for everyone of how we're gonna be able to strategize ahead, but we'll hopefully keep on the move. And so far, I think this has been a success Dr. Gupta and I and everyone has been happy with everyone's participation. Okay, we can keep the chat up going for a little bit, I think, but if not, everyone feel free to reach out to us. There was emails. We can't wait to see you in the lounge too during the conference. So hopefully we can carry on some of these conversations there.

injections

cancer patients

efficacy

Botox

steroids

epidural injections

pain management

quality of life

individualized care

high-quality studies

risks

side effects

research