Hi, thanks for joining us. We're being live streamed, too, so hello to everyone in the interwebs and the recordings. My name is Jessica Engel, and we are talking about emerging guidelines and clinical trials today, what matters in cancer rehabilitation, and we have some great panelists, Dr. Phil Chang, Dr. Ishan Roy, Dr. Neil Rakesh, and Dr. Hannah Hunter. We're going to be talking about cancer rehabilitation, and as cancer rehabilitation grows and grows as evidenced by this room, many years ago, we were in a very, very, very small room. We want to try to break down the silos and integrate whole person care in our practices, and we hope today's discussion with our panel of experts can initiate this, so we're going to have this short panel discussion, and then we will have questions at the end, and we will also be getting some live stream questions as well. Thank you. Hi. Good morning, everyone. Thanks so much for joining us. I'm Phil Chang. I work out of Cedars-Sinai Medical Center in Los Angeles. So thanks for everyone who came a lot further than I did. Okay. So I'm going to be talking about palliative care and symptom management. So to start off, just what is palliative care? So you see, like, the very big definition at the top from the National Coalition for Hospice and Palliative Care, and kind of, you know, what I say, palliative care is the people at the bottom, and it's basically just that it's holistic care that seeks to alleviate a patient's burdens, whether physical, emotional, or spiritual, at any phase or any stage of serious illness. And, you know, kind of the key words here that palliative care practitioners like to throw out a lot is just any phase and any stage. So it doesn't matter whether you're early in disease or kind of later with more advanced disease, at any point, referral could potentially be appropriate. Obviously, you know, other people much smarter than me have probably also used this kind of definition, too. So palliative care has been around for kind of a long time. Modern hospice probably got its start around the 1960s by Dame Cicely Saunders, and it's grown tremendously from there, and they've really worked their way into most of the National Society guidelines. So these are guidelines from the National Conference of Cancer Network, and they basically state numerous indications that are kind of listed at the bottom in really, really small font there. But basically, if anybody has physical distress or psychosocial distress or has questions or concerns about advanced care planning, then these would all be appropriate considerations to refer someone for palliative care services. The Commission on Cancer in 2020, their most recent guidelines, they've also stated that there should be policies and procedures in place for referral to palliative care as part of a certified kind of cancer program, but by their organization. And ASCO, the American Society of Clinical Oncology, also states that there is a moderate quality of evidence supporting a strong recommendation that clinicians treating patients with advanced illness and cancer should be referred early in the course of their disease alongside active treatment of their cancer. So it's kind of crazy how much influence a single person can have on a field, but Jennifer Temel is largely responsible kind of for a lot of kind of, you know, what's been happening with the growth of palliative care, particularly in cancer care. So this is one of her studies that basically just showed that early palliative care referral can basically lead to increased quality of life outcomes in patients with GI and lung malignancies. And of course, there's her landmark study from 2010, which indicated that early palliative care for patients with non-small cell lung cancer actually had increased survival in people who continued on normal standard of care chemotherapy, and they actually lived for two months longer. So whether or not this has been, could be replicated is not the issue, but just the fact that this exists and people are talking about it all the time is, you know, why everyone's continuing to kind of refer to them. So, you know, rehabilitation kind of has a ways to go. We are growing in the guidelines, but we're not mentioned as specifically. So again, from the National Comprehensive Cancer Network, they do mention that for these specific issues, healthy lifestyles, cognitive function, lymphedema, pain, usually musculoskeletal, sexual health, and return to work, then referral to physical medicine rehabilitation, they do use that term specifically, can be considered. The European Society of Medical Oncology states that for patients with cancer cachexia, for management of cancer pain, referral to rehabilitation can also be considered. And then probably where we kind of stand out the most right now is from the Commission on Cancer, and it's kind of thanks to some of the people in this room, actually, that we are mentioned as an important part of comprehensive cancer care in at least their eyes. So where does this lead us, and what's the role of palliative care in physiatry? So I think kind of just from my umbrella definition that palliative care is just holistic care for the patient, no matter what kind of physical or psychosocial distress that they might be going through. But don't take it just from me, the National Coalition for Hospice and Palliative Care, they basically say the same thing, that everybody should have like a standard basic set of palliative care skills. And this is basically what they say, that everybody should have some experience to complete palliative care assessments and address common sources of suffering. So this means that all of us, all of us physiatrists need to kind of put on our palliative care hats to be able to provide at least this kind of basic services. And I think that there's a fairly good reason for this. So you think about somebody who's newly diagnosed with cancer at whatever phase, and they have medical appointments and rehab appointments and social appointments, and maybe they're on research studies, and maybe they have, you know, they're different infusions, they're different diagnostic tests that they had to go through. It's so many appointments. And I think any time you can like cut down on that even a little bit and avoid like referring to another doctor a little bit, I think that can make a pretty big difference. This is just from one of my patients and her appointments, just like over the course of a month. I mean, like this is crazy, like your life becomes consumed by this. And it's not just transportation costs and parking costs, but it's like, you know, your time. And if you live in an urban area with a lot of traffic, it's just this can consume you. So I think any time we can take additional care on ourselves and avoid like, you know, having to expand the team, I personally feel like that's a very useful thing. So what are the things that we can do that I think are important? I would say one of the number one things is just advanced care planning. This is probably maybe outside the realm for a lot of us. And I'm not saying that any of us have to like have serious goals of care conversations and tell like break bad news or talk about progression of disease. I don't think that's our role. But I think we can do really simple things like explain what a health care proxy is or explain what a health care agent is. I mean, that's basically just, you know, the person that you designate to make your medical decisions in the event that you're not if you're too sick or in a coma or something. And you know, just talking about what an advanced directive is and how you can complete one. And it's very likely that all of your institutions have their own paperwork for filling out advanced care directives. I'm sure you can just Google search it and it'll pop right up. If it doesn't, then you can just direct patients to this website, prepare for your care. It's really simple. It'll take 30 minutes. If you guys haven't done it for yourselves, I think you should just as an exercise, not just, you know, in the event that this will happen to you because it's going to happen to all of us eventually. But just so you can get an understanding and explain to your patients. So I highly recommend that these are just really simple, concrete ways that we can start getting involved in advanced care planning. The second resource that I listed out here that I'm going to share with you guys recently is just through symptom management. And I'm just very briefly going to go through the National Conference of Cancer Network Guidelines for kind of more common symptoms that we deal with. But these are all available. It's free. You can go to their website, you can make a free account, and they have really, really amazing algorithms that will just tell you, you know, how you can treat a bunch of different kinds of symptoms. And it's just really easy to follow. And this is headquartered, I believe, it's out of Wisconsin. But it's basically like up-to-date for palliative care issues. You have like, you know, single page explanations of how to deal with different kinds of symptoms and different kinds of palliative care issues. So these are two really amazing resources, you know, if you want to kind of start getting your feet wet in palliative care and, you know, kind of providing that more holistic care for patients. So to start off, we have fatigue. So kind of listed, and this is just kind of my own personal bias, but at the top and everything in green is I feel like kind of the more effective things, acupuncture in particular, and probably number one physical activity. And I don't think there's doctors out there who are more qualified to talk about physical activity and exercise precautions than we are. And you can see also from the National Conference of Cancer Network in the box on the right, these are all like if anybody has a worsening, changing physical condition or, you know, like a history of abdominal surgery or peripheral neuropathy or musculoskeletal issue, you know, these are all things that technically are supposed to be evaluated by a physician. And potentially you might have to, you know, or it's recommended that you refer the patient to like skilled trained personnel for their physical activity. So again, I think as musculoskeletal experts, we are really, really well placed to, you know, give kind of the best guidance in these things. Moving on here on nausea, you know, it's really straightforward. It's just, you know, you take a different medication from all the different classes of medication and you just keep piling on different medications until, you know, their nausea is controlled. Me personally, everybody just kind of gets Zofran and Compazine to start with. And then if that doesn't work, then we'll rotate to Olanzapine. If that doesn't work, then we'll kind of add on Advan. Rarely do I add like kind of cannabinoids or corticosteroids, but it's, you know, it's pretty straightforward. Distress, I would really, okay, this is maybe one of those areas where you kind of do have to expand the multidisciplinary team, but, you know, so, you know, this is where your social works come in handy and, you know, when your spiritual care staff is really, really essential. And all these, you know, support groups, so, you know, the cancer support community, they're a national organization. They're not only in Los Angeles and they probably have resources like in your city. And CanCare is a nonprofit out of Texas and they do peer counseling. So there's tons of resources for this thing if you, this type of thing, if you just look. And then finally, anorexia. I'm not going to go over this because Dr. Ishan's going to go into it in a lot more detail. But the point is, is you just kind of go through the algorithm, you see what you can change, you see what you can alleviate, and, you know, hopefully people will be getting better. So with that, I'll hand it off to Dr. Ishan. All righty, so for those of you who don't know me, I'm Ishan Roy. I'm a physician scientist at Shirley Ryan Ability Lab. I focus on cancer rehab, but I do have a subspecialty clinic focused on cachexia management. And so today we're going to kind of take one of those areas that Dr. Chang was already focusing on and drill a little bit deeper in terms of the emerging evidence in terms of treating cachexia. And so I have no disclosures. And so just get everybody on the same page in terms of cachexia. You know, this is body weight loss, but really muscle loss and sometimes fat loss due to an underlying illness. Today we're going to talk about it in the context of cancer, of course. Half of all cancer patients will get cachexia at some point during their disease, and three-quarters of the patients who have advanced cancer will get cachexia. About a third of all cancer-related deaths can be attributed to some degree to cachexia, and then the vast majority of patients who have cachexia will eventually develop disability. So the FDA has not approved any actual treatments for cancer cachexia, and there's a number of different reasons why. But today I'm going to focus on the fact that the FDA is essentially requiring any medication for approval to actually improve not just muscle mass, but also function. And that has led to a lot of failures at the clinical trial level, despite a lot of good preclinical work that's been done in the last couple decades. Now it's not that cachexia patients don't improve in function. Our own data, which we've published in the past on our inpatient population, shows that no matter what cachexia marker you use, and that's the different colors in this graph, if you plot their gait function and their functional independence measures during rehabilitation, they all pretty much get better. And not only that, but their weight can actually get better during inpatient rehab. On the outpatient side, though, the evidence is a lot more thin, and that's because outpatient cachexia programs, to some degree, have been run mostly by palliative care, both in the United States and worldwide. And so the focus has been largely on improving symptoms, and then the evidence is largely related to that, too. So outpatient programs do improve weight and quality of life, but there's not really actually any evidence on improving function. And so at my clinic, or our clinic at Shirley Ryan Ability Lab, we're much more focused on implementing customized and integrated rehabilitation plans, and meeting patients at sort of what is their level of physical impairment. So if someone has ADL issues, then we're focusing on that, but if someone's much higher functioning, then we might be focusing on exercise tolerance or building muscle bulk. And of course, that's still happening in a multidisciplinary setting with dietary medicine and palliative care and the primary oncology team. And so we kind of take a threefold approach. We focus on optimizing nutrition, again, with dietary medicine, and reinforcing some of the education that they do. We then focus on nutrition impact symptoms, and that's what Dr. Cheng had on that last slide, which is the sort of symptoms that indirectly or directly affect your ability to take in nutrition, whether it's nausea, diarrhea, constipation, of course, directly appetite or anorexia, and fatigue. And then the last part, as I was alluding to, is then that customized physical rehab program that may involve PTs, it might involve OTs, or it might involve exercise physiologists. Now broadly, in terms of that nutrition-related symptom management, there's a lot of different medications that are available to us. There's a lot of non-medication approaches that you can take to a lot of these too. I'm not going to go into this into a lot of detail, because I want to spend a lot more time on appetite management, but feel free, anybody who's taking pictures, I think I had a similar slide last year. But this is what we're going to talk about today. And so, you know, up until 2022 for sure, and early part of 2023, there was no first line, second line, third line recommendations for managing appetite. But what changed is in the summer of 2023, ASCO came out with a recommendation saying that olanzapine should be first line for treating appetite issues in cancer patients. And today, we're going to talk first about the paper that drove that recommendation. And then in the last part of the talk, I'm going to mention a new and emerging treatment that's at the phase two clinical trial level that I think will change practice management for cachexia for good. So let's talk about olanzapine. So the study that ASCO primarily focused on was this randomized double-blinded placebo-controlled trial from southern India, where they looked at GI cancer and lung cancer patients who were about to undergo chemotherapy. And for three weeks, then they gave them 2.5 milligrams of olanzapine daily. I think it was usually given at night. And then measured, did they have change in appetite, did they have change in quality of life, did they have change in body weight? And what they found was that very consistently, those patients who got olanzapine had increase in their body weight of at least 5%, but also over time through the course of chemotherapy. The same patients had significant improvement in malnourishment, which there are specific clinical criteria for, quality of life, the amount of calories they took in improved, and then equally importantly, their toxicity from their chemotherapy was reduced. So the take-home message is that for now, it appears that olanzapine is the only appetite stimulant that's been shown to be superior to placebo that's available in the US. I say approved on the slide, but it's really available in the US because there are drugs available in other countries. So anamorelin, which is a leptin-grelin axis targeted medication, is available in Japan. The reason why it's not available in the United States is because of that FDA requirement that drugs need to improve function and not just weight and muscle. And even here in the US, olanzapine is not FDA approved for cachexia either, it's just that it's available to us for off-label use. Now, the last point I wanted to make, or the second to last point I wanted to make is actually that the most common side effect from olanzapine, which I think most of us are probably aware of, is drowsiness. And this wasn't extensively discussed in the clinical trial from India. But at least in the last year when I've implemented this into my practice, there is a sizable minority of patients who report that drowsiness even at that lowest dose of olanzapine. And for some people, it's a double-edged sword because for some people, they have sleep disturbances which are very common in cancer patients undergoing treatment. And so we end up improving their sleep cycle, and for other patients, they just can't tolerate the drug because they get tired during the day. The last part, though, is that there's still not evidence on actually improving muscle at the biological level or whole body physical function in terms of olanzapine. So there's still more research to be done in terms of what's olanzapine's role as a single agent versus in a multidisciplinary setting or a multimodal setting. All right, so let's switch gears to emerging treatments and talk about GDF15. In the last two decades, there's been a number of different cytokines and myokines that have been studied for related to cancer cachexia, and GDF15 has gained a lot of steam in terms of focus from a basic science standpoint. And part of that is because this is a cytokine that's secreted during physiologic stress by a number of different tissues, including muscle and liver and heart, and it localizes to a few different areas. One of them is the brain, and when it gets to the brain, it affects appetite centers. And not only that, but further preclinical data has shown that it can be secreted by tumors and have direct effects on muscle, and when it gets to the brain, it's not just affecting appetite, it's affecting sympathetic outflow. And so now you have one particular factor that's at the cross-section of a number of different components of physiology that all fall under that sort of cachexia syndrome or function-related issues. So even in our own lab, you know, when we've done pilot studies where we've looked at, for example, in this study, half of the lymphoma patients who were getting chemotherapy and half of them ended up needing rehab and half of them didn't, when we looked at levels of different cachexia-related cytokines in these patients' blood over time, over different cycles of chemotherapy, we found two different markers that consistently were elevated and then elevated over time. One of them was TNF-alpha and the other was GDF-15. So there's clear sort of early evidence that, you know, GDF-15 might not just be related to appetite but may have some predictive capacity for function as well. Of course, the drug companies have gotten pretty interested in this, and Pfizer in particular has created a monoclonal antibody for GDF-15. And so just two months ago, they published a New England Journal of Medicine study. It's a phase two clinical trial on Pensegrimab, which is that monoclonal antibody. This is a randomized, blinded, placebo-controlled trial conducted across 11 different countries. And again, it was a 12-week intervention where they found patients who had elevated levels of GDF-15 in their blood and then gave them a titration of Pensegrimab and then looked at body weight, looked at anorexia based on patient-reported outcome measures, and then physical activity through wearable devices, so basically step count. And what they found was that there was a clear dose-dependent increase in body weight with Pensegrimab. And then if you do subgroup analysis, you can see that in particular colon cancer patients did better. Patients who were not getting platinum-based chemotherapy did better. But also, patients with the highest severities of cachexia and higher inflammation markers were responding to this medication. If you then do some secondary analysis just at that highest dose, 400 milligrams subcutaneously, we see those patients clearly have decreased anorexia. They also have increased physical activity per day. And when you use imaging-based measures to measure actual muscle and not just body weight, you see increase in their skeletal muscle index. On the flip side, when you're looking at adverse events, there is no dose-dependent relationship in the adverse events, suggesting that there's not necessarily an obvious adverse event that's happening related to Pensegrimab, especially when the adverse events were also prevalent in the placebo-controlled population. And so with that, some take-home messages from this brief talk. One is clearly cancer rehab plays a role in multidisciplinary cachexia care. Olanzapine is probably a stopgap measure for treating anorexia. We need more evidence, though, in terms of how it could potentially influence muscle and function, especially when combined with rehabilitation. And then Pensegrimab, or really the broader category of GDF15-targeted therapies, is an emerging strategy that can address weight, muscle, and function, crossing multiple domains of the cachexia syndrome. Now, right now, there's an open-label extension going on for that phase 2 clinical trial, meaning that those patients are continuing past 12 weeks and continuing to be treated and seeing if there's sort of longer-term effects from being treated for that medication. So we're not at that phase 3 level yet. So we're probably at least a few years away before this is going to hit the market commercially. But when it does, I think the cancer rehab world will kind of have to step up and say, OK, what's the role of physical interventions in combination with this drug? And so we have some time to get prepared for that in terms of sort of what our physical intervention programming should be and how it should be added to this equation. And with that, I'm going to hand it off to Dr. Rakesh. Thank you. I'm one of the cancer pain doctors at Memorial Sloan Kettering. And today I'm going to talk to you about interventional cancer pain. I know it's a little bit different than what everyone's talking about, but as we said, you want to have all of the services involved and all of the care because there's many things you can do for these patients. So let me give you a little context. And before that, this is my disclosures, nothing crazy for what we're talking about today. But let me give you a context. So in terms of cancer, the most common cancers for men are prostate, colorectal, and then lung. In women, it's breast, lung, and then uterine and colorectal. And this is important because I always think etiology of what people's pain are is important to figuring out how you can interventionally kind of intervene on these things. If you don't know the actual reason for why it's happening, it's kind of useless. In terms of the amount of patients that end up having pain, there was a study done by Vanderbuken in 2016. This was a review. And for all cancer patients, about a 38% of them are going to experience some form of pain that they're going to have. As they start going through chemotherapy, radiation, this is going to start to jump up a little bit more. This is going to go to about 39% to 55%. Now if you have those patients that go to the metastatic diseases, they get much worse, they go towards the terminal diseases, their hospice, this jumps up a lot. This is about two-thirds of those patients are going to have a lot of pain. That's going to be pretty disabling for a lot of these patients. And so what do we do for those patients? Well, this, as you guys probably remember, this is a rendering done by AI. This is Dolly. And if you look closely, you can see it doesn't look great. But you do know the whole ladder. You have seen this before. And I like to just kind of show that because it's a nice framework for how people escalate medications. You start obviously with the non-opiates, and then you work your way up to the opiates and the higher doses of things. But I think this is relatively incomplete when you think about the interventional aspects of things that we can do. So this is my little take on the thing on top of this. So what it is is the interventional tier system. And all of the medications, all the therapies, all the other things, the alternatives are happening at the same time, as you can see in the bottom down here. But at the same time as this, you're doing the interventions to try to limit the medications, to try to make things better so they can functionally kind of do the things they need to do, whether it's get through chemotherapy, radiation, whether they want to even just be mobile with their family, be able to communicate with them. Because these opiates and all the other medications really take a toll on them. And so when you start with the very basic things, tier one, simple injections, steroids, botulinum toxin, prolotherapy for some people. And then if that doesn't work, you move to the next things. You start doing some of the temporary implants like peripheral nerve stimulators. You can do neuralyses that are low risk. And then if that doesn't work, go to more permanent things, cryoablate things, ablate nerves, kill things. And then in the worst cases, people that don't respond to any of those things, you can do the highly interventional things. These are the things that we do in neurosurgery, interventional radiology, so kyphoplasties, implants for pumps, stimulators, chordotomies, which all are very, very useful technologies and things you can do for these patients to try to provide functionality for them. So how do you choose what to do and how do you think about, like, a thing? And I always like to provide a framework for things and how you think through problems. And the first thing you want to ask is, what is the time frame in which you need to treat for these patients? Is it something that they are suffering so much that they can't go through their chemotherapy or radiation? Do you not have the time? Do they show up in the urgent care and you have to do something just to get them out? Because if they're in urgent care, they can't get their chemo, they can't get their radiation, they can't do the surgeries they need to do. And so I think of that as the comfort-based approach. And a lot of times when you do this, this is kind of like a wide swath of things you may do. But an example of an interventional thing is an epidural, an epidural catheter, specifically. And the downside of this is you lose functionality to some degree. If you put a lumbar epidural catheter, for example, it's going to infuse local anesthetic and they may have difficulty walking. But the benefit is, is they will not have a lot of pain. And so we do this for a lot of patients that are undergoing radiation, for example. They can't lie down on the table and put this in. It makes it super easy for them to go through the radiation and they can get through that process. If you do have the luxury of the time and they're outpatient and you can figure out the exact etiologies, which I kind of always tell people etiology is important. That's what I said in the beginning. Then I do what's the precision-based approach. And this is what you guys are all very well familiar with. This is like the sports world and everything that we've kind of trained on. Someone has radiating pain in the shoulder-based pathology because they have interarticular pathology from tumor or radiation or things like lytic lesions. You can specifically target aspects of it. So a shoulder injection, the nerves associated with it. There are a lot of things you can kind of go down in that path. When you've figured out your approach, then you figure out how you want to target it. And there's two ways in which I think about this. There is a referred approach and a regional approach. The referred approach is what everyone would think when you think of a referred pattern, like a dermatomal, a myotomal, a peripheral nerve pathway. So a prime example is someone that has radicular symptoms down to their foot. You don't do an injection in their foot. You do an injection in their back where the radiating pain is coming from. So you do an epidural. A regional approach is different. It's if there is pain in a specific area. So post-mastectomy pain, for example. People have chest wall pain. Very common thing after the surgeries and people can develop chronic pain syndromes. A regional approach is targeting the nerves, the small peripheral nerves, the muscles, as well as the inflammation that's in the area. So doing a serratus plane block is something that you do for that particular patient. And so it's useful to kind of understand the difference between those two. And that's kind of always how I'm thinking through this. So let's, yeah, I forgot. This is also just a large swath of just procedures. I just made this for the fellows because they sometimes have no idea what they're doing. And I was like, where is the pain? And then these are the types of injections. It makes it simple. But I do kind of tell people, understand why you're doing what you're doing. And then you can figure out these things as a result of that. So this is a useful little diagram that I made for the fellows just to make it easier for them as they're going through training. I want to kind of delve into a little bit more of specific things. Because I could go through every single kind of cancer and pains that exist there because I've seen so many different things. And that would take hours. I could do lectures for hours on this. But let's focus on one specific thing. Post-mastectomy pain. And as I said in the beginning, what is the etiology of pain? These are the many different reasons why people could experience pain. Nerve injuries. One, it's very common. You could have the intercostal nerve, intercostal brachial, which everyone is very common. That's a board question that everyone probably remembers. It can even be the small peripheral nerves that exist in the area as well. People can get central sensitization phenomenon. So there's phantom breast pain, for example. That's something that people can get. You can even get central sensitizations from wind-up phenomenons, phenotypic switching, sympathetic coupling. There's so many mechanisms by which people can get central sensitization. You can also get inflammation in the area. So from radiation, for example, or from the surgeries that happen, that is a very simple pathology of why things happen. That's why people respond to anti-inflammatories or steroids a lot of time when you're doing this. The myofascial pains. Again, everyone is very well versed in these. There's lots of muscles that are implicated. And I'll go through some of those things. But you can even get myocytoses as a result of the radiation that you're doing in the area. And then you also have lymphedema. Everyone is kind of familiar with this. And then the hardest one, I find, is psychogenic. This is oftentimes just compounded with all of the other things that are happening. People have anxiety and depression as a result of the pains that they've had for a long period of time, or maybe they had it before. And it compounds, and it makes the pain exponentially harder to treat. So oftentimes, you're treating all of these things at the same time. And I find psychogenic to be the hardest one. Now, what's the evidence for this? What is the evidence in terms of interventional things for post-mastectomy pain? I think you guys are going to be a little disappointed, but I'll show you anyways. Not a lot. Not a lot of evidence. And the reason being is most of the studies in post-mastectomy pain is not chronic post-mastectomy pain. It is acute interventions that people do. So you'll find large, robust, randomized trials on perioperative medicine. So do you do regional blocks before? Which ones help? Perivertebral, serratuses. What helps to try to limit the post-operative pain? Do they have pain that they develop as a result after that? That's what you're going to see. The chronic pain stuff is actually really sparse. And you're going to see these large kind of case series that are not like super well supported. But here's a few of them that actually had a decent kind of look at things. So one of the first ones was a trigger point study that was done in 2021. And this had 43 post-mastectomy patients. And they targeted a large kind of swath of muscles. It wasn't really anything particular in this one. Just where the area of the pain was. They did trigger points. And they ended up finding the majority of them had relief. And it ranged from three months to three years. And I do want to bring that up. That it's important to understand that they didn't stratify their patients as this is immediately post-surgical. Like it's three months after surgery. Versus someone's had it for three to five years. And that's an important distinction. Because people can get three years of relief from a trigger point. Because they were going to recover from the surgery to begin with. So I just want you to understand that difference of why that thing is so large in terms of the range. The side effects, minimal. Like irritation, skin redness. Nothing crazy in terms of infection. So it's a very low risk thing for these patients. And a lot of reward. Same thing. In 2014, we have another study on specific muscles. So the pec muscle and the subscapular. They had 19 women that they did the trigger point injections on. And they had significant improvement. At three months with an increase in range of motion. And it is important to understand why these muscles specifically. So the pec muscle, when you do the surgeries for mastectomies. Oftentimes they'll move it and distract it out of the way to try to think. Some people will lift it over. When they actually go back and they suture it back together. So people can have pectoralis muscle a lot of time. When they have anterior chest wall pain or lateral chest wall pain. The subscapularis is an interesting one. Because oftentimes surgeons may do flaps to try to kind of salvage tissue. If they have to cut away a lot of tissue. And so you are distracting the subscapularis as well as the lat muscles. And that's why, that kind of explains why a lot of these patients had the subscapularis affected. And they found, again, just like the last one. A lot of relief and very little side effects. No complications. So super safe thing. Now if you delve even further, it gets really interesting. So you can see like some of the central pain stuff as we talked about before. They've done studies on things like this. So stellate ganglion blocks. And specifically alcohol neurolysis and pulsed radiofrequency ablation. And what they found was these patients had relief. Both of them had relief. But when they compared them head to head, the neurolysis actually was significantly improved in terms of VAS scores between the two. And this is at four and eight weeks. And very little complications. So there's a lot of interesting things out there that have been studied. But it's not super robust in terms of these large randomized trials of specific things. But I don't want to leave you with just that. I want to give you a framework of what to do and what to think. And so this is another thing. A thing created for the fellows because sometimes they have no idea what they're doing. And so when it comes to chest wall pain, especially for postmastectomy, think of it in this way. Where is the location of the pain? If it's anterior in the middle, I oftentimes do things like a superficial thoracic plane block. If it is slightly lateral or up here, I'll do a PECS block, a serratus block. On the back, an erector spinae block. If there is involvement of the visceral organs, so let's say someone had a lung surgery or a VAT surgery, I may target the perivertebral. Which is an area where it actually encapsulates the sympathetic fibers. And you'll actually realize a lot of these are regional approaches. And that's because the pain that people get oftentimes is as a result of the inflammation or the irritation in the area. It can be small sensitization of those peripheral nerves. And it could also be that they have tightness in these muscles. Steroids can have a toxic effect to scar tissue. In this case, it actually helps. It helps break down the scar tissue and makes them more mobile as they're doing the things. Again, this is an adjunct to everything we've talked about. This is not a replacement to saying that don't do physical therapy. This is a means to improving function. This is not the only thing to do. And that's the disclaimer I want to give everyone. The point of this is to make everything easier for them to get to where they want to get to. So, with that, thank you so much. Great. Thank you, Dr. Rakesh. I wasn't sure if he did an intro. Did you introduce yourself? Yeah. Part of the team at Sloan Kettering. And I'm going to conclude us with a talk on collaboration and kind of introduce the idea of the need for better screening of our supportive care colleagues and cancer rehab physicians in the room. We're all trying to do a great job. But a lot of times getting patients to the right service in a timely way is incredibly challenging in terms of feasibility. So I'm going to share two things that I think a lot of us in the room would consider somewhat obvious is that we've seen these webs of supportive care symptoms that we treat, such as fatigue. And there's multiple aspects or drivers of symptoms like fatigue, whether it's a treatment related side effects, a change in sleep pattern, pain, maybe anemia. And we see these webs and we're like, yes, all these things contribute to fatigue. But patients, if we put a patient in the bubble of fatigue, everyone's a little bit different. And so our treatment for fatigue can't be a bandaid of like, go walk or go exercise. It should be tailored to what patients are experiencing in that moment of time where the fatigue is impacting their quality of life. So if we look on the other side of the screen of seeing this patient might not have anemia, they're eating well, their sleep is great, but their main drivers of their fatigue are pain control, mood and inactivity. And our supportive care approach or rehab approach should be tailored specifically to that. And the other point I want to make is we know that our supportive care interventions, whether it is rehab, physical therapy, optimal pain management, also ripples into other domains related to quality of life. And so if we're treating fatigue by increasing physical activity and exercise, that may also improve their sleep and that may also improve their pain levels. So there's like this web that we see of symptoms driving other symptoms and our treatments hopefully improving other domains related to quality of life. And I think our oncology colleagues have recognized this. There's been a lot of emerging research and implementation of better understanding risk profiles for patients undergoing treatment, undergoing major surgery and a push for geriatric and frailty screening. And I think this is the way our oncology colleagues have been trying to figure out, like, what supportive care needs do people need? And we've done a good job of recognizing patients with this phenotype of frailty do worse. They have worse outcomes. They poorly tolerate treatment. But what do we do next to implement a supportive care plan that's actually going to make them better candidates for treatment, decrease the adverse events that they experience during treatment? The interest in frailty screening or geriatric screening has gained a lot of momentum to the point where ASCO recommends routine assessment of functional age for older adults using a geriatric assessment. But I think a big question for us as rehab colleagues is how do we partner with our oncology colleagues in doing the screening but also feasibly integrating rehab? And I think I just want to bring up the point we talk a lot about prehab and I think this these patients who experience frailty is a population where we can, I would advocate, do the most good. Like if we know patients are fit and they're active, they will likely benefit from continuing to stay active. But if we can take a patient with this phenotype of frailty and make them a candidate for treatment that they otherwise would not be a candidate for, I would say that's pretty awesome. And this, I won't go into all of these, but just showing that there's this interest of trying to figure out how to better collaborate and screen patients for supportive care symptoms. I want to highlight one article that was published recently in Lancet Oncology on patients with hematologic malignancy treated with CAR T-cells. So the authors looked or reviewed a bunch of research that was looking at patient reported outcome screening in patients treated with CAR T with hematologic malignancy and their goal was to create this construct of understanding these different drivers of symptom burden and treatment tolerance and you can see lots of symptoms like symptoms and organs or possible dysfunction that occur in patients that contribute to symptom burden that then impacts tolerability to treatment, quality of life, which then affects how patients are actually treated and their disease progression or disease treatment. And I think this is relevant because the goal of this is creating this conceptual framework of a easy to do, an electronic patient reported outcome system. And electronic patient reported outcome, so using the EMR or using digital health to in live time capture what patients are experiencing is known to be acceptable for patients, timely, increase the time to referral to the supportive care resource. So I think this is where we're going in terms of not just relying on patient encounters or when patients are seen during infusion to ask about their falls or ask about their nausea but get real live time patient reported outcomes that then drive supportive care referrals and needs. So I want to share a little bit about what we're doing at Fred Hutch. So I spent my clinical time both at the University of Washington and Fred Hutch Cancer Center and we in the past year and a half have been collaborating as a supportive care team on screening and we've developed the supportive care questionnaire where every new patient at our cancer center is given a MyChart or electronically delivered survey. When patients collect the survey, if they do it online they have the option to do it in person in paper because some people still like paper. The survey will automate different referrals or different pathways depending on what the screening is for. So we've tailored this to be different at every community or regional site as well as our main clinic because again we can't just give everyone referrals and expect patients or oncologists to be able to do this on our own. So if a patient is seen at our Seattle location and they screen positive let's say for a need for PT that PT referral is different in our Seattle clinic than it is 45 minutes away at a community clinic. It's to a different location and the pathway is different for the oncology team. Same for nutrition palliative care. So it's based on a pragmatic approach of like what patients would do and what works in the hospital system. For non-billable services I'll just switch between these two slides. So we have embedded kind of social drivers of health screening as well as supportive care needs. There are services in our supportive care team that are non-billable services. So those are all auto referrals. So if it doesn't require a physician referral something like patients screening positive for food insecurity or difficulty with transportation that will go to the promise cancer function screen with the idea we've kind of given each answer a numerical value or a number. So if patients are saying like let's say this first questions are you able to go for a walk of at least 15 minutes without any difficulty gets a five unable to do gets a one. So if patients are screening a 24 or less and there's 12 questions so usually saying with a lot of difficulty you're unable to do their screening positive for physical therapy on our screen. Another easy question that we have is malnutrition screening. That's an auto referral to our nutrition team and the page Q9 for social work and psychiatry. And again I want to highlight this kind of has worked in our system. I think we've have say over 15000 completed or sent out screen. So patients are willing to fill this out. This is like when they establish care within our cancer center. And we're trying to be proactive. And so this model may not work at other institutions or community practices but again we've learned that we've had to tailor it to each clinic with every supportive care referral being different depending on resources available at that site. And I thought this was really clever but I would advocate that when it comes to support of care that we should have a pact of having a personalized approach of what makes sense for patients being proactive rather than waiting for patients to present with cachexia of trying to screen them early collaborating so we can work with our pain colleagues or palliative care colleagues early to address those symptoms that are multifactorial and timely. And I think there is a lot of interest in this in the idea of implementation science of how to make this feasible how to triage patients how to risk stratify patients and this was an article published somewhat early or this year on palliative care needs and how a triage system was using used a digital health means to get information from patients and then triage them to different resources that they would get through the app on well whether a self-management of patients learning how to manage symptoms on their own referral to community programs or following up with their provider. So I think we'll see a lot of iterations of something like this in the support of care space over the next few years. So next I think we'll have our speakers come up and we'll take questions both from the virtual audience and in person. Thank you so much for your talk very very informative. I wanted to ask for the non-palliative care cancer rehab docs. I find that as I get older I'm treating a lot more conditions that other physiatrists may not treat in my cancer rehab clinic. You know sexual dysfunction depression anxiety you know all kinds of things which I'm fairly comfortable with but just thinking about you know treating cachexia right. So I really like what one of the speakers said trying to minimize how many physicians we send our patients to right. So do you see you know treating cachexia within cancer rehab scope or is that something that's in the future or is that something that is best collaborated with oncology and palliative care. So I can I can speak to my experience in my clinic. I'm curious to hear what others have to say but I mean to me it it it doesn't really fall under the scope of practice of palliative care entirely because you know it's not a it's not a pure symptom problem. It's clearly a function problem and that's ultimately why I think patients care about it. You know you know clearly you know having lack of appetite can be disturbing on its own distressing on its own. But at the end of the day when a patient's weaker that's when they tend to care about it. So to me it falls squarely in the in the realm of scope of practice for physiatry in general not just cancer rehab especially since cachexia is not specific to cancer. It's also present in a lot of other disease states that we end up taking care of. So so for me right now as of this moment I think it's it does belong in physiatry. I think with the emerging medical therapies we run the risk of being excluded from the physical intervention standpoint if we don't make ourselves present in the care of cachexia right now. And so let me give you a brief example of why that's a problem right now. So if you if you search for evidence for exercise in cachexia you'll see two Cochran reviews one from about five years ago or it's actually more like 10 years ago that said there was no studies that were useful at all. And then one from about two years ago showing that the studies were extremely poorly designed and didn't have great outcome measures. And to me those are problems that physiatry could have solved. And so we need to be at the forefront of designing these clinical trials that include physical interventions in addition to that sort of greater greater multimodal multidisciplinary approach. Oh sure. Yeah. I guess I could just add something. So I don't know. I guess when I think about it like if it's something you can do it's like within your ability to do it you're trained in that you feel comfortable doing it. I think you should just do it. Like if you can do your own procedures no offense to our wonderful interventionalists and there's a million things I can't do but I think you should just do it. Obviously I think you know if there are certain situations at your institution where some things just might be you know totally like off the table that you shouldn't do because I don't know. There was an argument years ago with whatever department chair then fine. Like maybe not or maybe that's a gray area. I don't know. But I think yeah if you can avoid referring to other people I think that's better. And I think patients like it. The one stipulation I'll make is like you know when people like ask you to kind of serving their primary care doctor and I know there's a lot of you out there who are doing this even that I think is kind of personal but maybe yeah I would I would even say that's kind of a gray area. But I would say you know if you can do it then do it. Hey thanks really great presentation. I'm curious if you guys have any thoughts or experience with people with like post exertional fatigue exacerbations. It's something that I got to get clued into with the post covid data that's coming out and I certainly notice a subset of my patients just really I give them my spiel about exercise is good. Try to do it push through and they come back and they're like I I try it I can't. It's just we have no phenotypes for these patients even the post covid population I'm just curious if you guys have any thoughts or experiences with them. I think figuring out that right exercise prescription is key because patients can be the most motivated and overdo it and then feel like they just saw seesaw between overexertion and needing a lot of rest. I gratefully have the opportunity to work with a rehab psychology team and we've just integrated them into our cancer rehab practice and clinical site because I think even because working with them figuring out that pacing energy conservation like day to day routine how to offload like using even from cognitive fatigue strategies of like using using a pill box so you don't have to think about like what medications that you took that day or using different strategies to pace is really key both from the cognitive fatigue standpoint and physical fatigue standpoint and so we can recommend the exercise but I think working with someone with whoever that is in your institution to figure out what is sustainable and doable on a good day or a crummy day is key. I can stand in there for when I see fatigue patients in clinic I'm sort of right away trying to differentiate whether they have symptoms that are physical purely or whether they're more central or cognitive and if they are if they have that sort of central or cognitive phenotype then for me it becomes critical to bring in psychology services and you know there's not a lot of literature on this but if you look in the chronic fatigue literature separate from cancer there's some studies that suggest that CBT in combination with exercise is effective whereas exercise by itself is not as effective obviously CBT and you know when we're talking about more appointments for patients is a really tough ask for cancer patients you know but what I'm doing for now is at least trying to get them roped into counseling services if those aren't available to begin with and then you know obviously CBT can be done for many different reasons and so I give some guidance on what that CBT should look like it should be focused on their fatigue related issues I'll just really quickly throw in like for fatigue in general I think the NCCN guidelines have like a really nice framework for just addressing irreversible causes and yeah there's a lot of evidence they call it category one evidence meaning that there's strong evidence plus uniform uniform consensus among an expert panel that you know this is like a useful thing to do but not just CBT but just psychotherapy like mindfulness based relaxation and you know these are just like YouTube videos that people just like you know watch like a relaxation video where like there's you know hundreds of like apps for this kind of thing that are like easily accessible so just another thing to consider. Thank you for an excellent presentation learned a lot in the different areas within cancer rehabilitation so I actually have two questions on two separate topics the first one is to piggyback on what you just discussed I'm noticing with some of the patients and the caregivers within my population's depression and dysthymia has a very big impact and I was wondering is there any new literature that comes out in terms of timing when to make referrals to a psychiatrist or CBT or psychosocial interventions or having a discussion with your patients in the course of the cancer rehabilitation guideline whether it's in you know a prehab pre-rehab context with surgical patients potentially or it could be when you are triggered the referral or later in the course of the disease when you're doing advanced care planning for instance so that's my first question. So is your questioning about timing of rehab services or timing specifically of rehab services for depression for screening for depression and then referrals accordingly there's been a lot of you know literature coming out of when would be the most effective time to do it. So I'm personally unfamiliar with any recent literature regarding the most effective time all I could say is like in all of our clinics or like the PHQ-2 and PHQ-9 is like a routine part of screening for all patients regardless of where they are at in their disease course so whenever there's a positive finding it automatically gets sent to our social workers they automatically get screened for psychiatry referral so yeah it's kind of automatically set up in our clinics. I assume a lot of other cancer centers probably have similar practices but yeah I guess my only recommendation would be if it's not then the PHQ-2 it's really simple like just two questions takes like ten seconds but that might be something to consider. So PHQ-2 at the time of referral okay because I see the nine floating around and I you know there's just I see different centers or different individuals doing different things and I was just wondering what's the most effective? Our hospital standard of care is the Nine. And that's not specific to cancer patients. I haven't found it to actually be that sensitive compared to when I'm asking about history of mood issues or depression for people who have ongoing physical function issues. And then I'm asking, oh, do you have a history of this? Let's say somebody comes to see me for fatigue, and I'm trying to suss out the risk factors for central or peripheral fatigue. I still have to ask the question of, do you have a history of mood issues to determine their risk for potential cognitive fatigue moving forward? OK. So I don't, I mean, I think the tools are helpful, and screening tools should be implemented. But it hasn't been studied yet. Right. And that's what I want to know. Well, there might be one exception. So Dr. Chang brought up Jennifer Temel's study. She's part of a larger supportive oncology group at Harvard. And William Purill's probably the driving principal investigator in that group. He was on that NEJM article. And this is what he does. He's probably the one person who is starting to push forward in that direction. But it hasn't changed guidelines yet, as far as I know. Thank you. And the second question is what we've seen in the beginning of COVID, at least in my practice. There was a big push in virtual care. And several, I've had a lot of noncompliance with my patient population before with a lot of the rehab referrals and services, whether it's nutrition, exercise, even therapy. I've been developing models internally, and we've been tracking it with our patients, that having a hybrid model, where you track noncompliant services, you do a case control based on time before that, some of them providing adjuvant virtual options could improve compliance specifically with nutrition for some cancers, I find, with exercise when appropriate, and especially with the psychosocial aspect as well, mind, body, medicine. Have you studied that? Have you seen anything in the literature showing that there is better engagement rates, better outcomes with that in the past five years? I can't speak to the research. But I think there is a push to make access to supportive care services or provide them in a patient-centric way. For us, and I think Sloan uses the care neighborhood model of patients staying. Let's say they're coming for infusion, that teams will see them. So if patients are on site, that's when our registered dietitians will see them during infusion. Same with spiritual health and even our psychology colleagues coming to them if they're on site and have shared decision making about what patients prefer in terms of feasibility, transportation, and other barriers and challenges, and understanding what of those are modifiable and what patients prefer. OK, thank you. I can just add, there isn't literature on this timing and intervention question as far as I know. But to the point that Dr. Hunter just brought up, particularly the patients that are undergoing chemotherapy, they're the ones that are the trickiest in terms of timing, in my opinion. And actually, at our institution or our cancer center, they're taking a slightly different approach, where the oncologists are not seeing everyone every time they get an infusion. It's usually about every other or every third visit. And what they've realized is that the in-between visits, you don't necessarily have to have the infusion on the exact same day. So if the patient is flexible and supportive services are not necessarily available on every single day that the patient might be coming in, then they'll actually shift the starting day of chemotherapy to match when social work is there or when psych onc is there, for example. And we haven't tried that yet with rehab, because we're a standalone facility. But we are starting to think about that as a pilot for actually shifting chemotherapy to be when the cancer physiatrist can see the patient. So listening to both of you, then, from what I'm listening to, there hasn't been really a push for evaluating virtual care for these patients. It's usually when they're getting their treatments or coming into the facility. And it seems like you're getting good engagement rates with that. Am I correct? Thank you. Or just to add something really quickly. So this is something where the last time I looked at this literature for adherence virtually versus in-person, I didn't see many studies like a year ago. It might be different now. Most of the studies are looking at efficacy, like if you can get similar outcomes with in-person versus virtual. But we have one subgroup that was formerly like the telemedicine subgroup. So we're currently working on seeing if there's an adherence difference. So I don't know. We can get the study off the ground maybe in two years. Thank you. Thank you so much. Thank you for your talk. I'm Erin Kelly. I am a PM&R and palliative doc. So I bring that up because we do the stress screening. So I have different thoughts about that. But when a patient is first diagnosed with cancer, they get a distress screening. And then it's based on what they kind of screen positive for with the referrals. My question is more, I think, for Dr. Hunter. For when do you refer people and re-evaluate them? It seems like you're doing it at diagnosis. But is it more reactive along the way when patients need to be referred to different supportive services? Or do you screen it 30 days in, or when they start a new regimen, or something like that? Great question. So I think of our screening or referral to supportive care as kind of this four-pronged approach. One is this screening that once patients establish care at our cancer center, they get this long questionnaire. But that's not repeated. And then the other three would be during patient clinic encounters, whether it's brought up by the clinician or the patient themselves of saying, I have this need or I have this symptom, and the other being disease-specific protocols. So we have some patients who we have dedicated timely screening for our GI on patient population. They get malnutrition screening, I think, after X chemo infusion. So that's repeated. And the other is supportive care cross-referrals, or that's the fourth. And so we have protocols in place, or QI initiatives in place to provide timely referrals to patients once one of our other supportive care colleagues notices a symptom. So when a patient newly screens positive for malnutrition, if they see a registered dietician, that will spur on a referral to our rehab team. And we have other things in place. But we don't have something set for all patients. But it's more disease-group specific. And I think it also matters what works for your institution. I can just add for our cachexia program. We found that at-diagnosis screening doesn't lead to, then, engagement with the extra services. And so our dieticians have actually shifted to looking at screening at first infusion when the patient has a lot more time, and they've had time to process their cancer diagnosis. And they've already become engaged with the treatment process of their cancer itself. And then they're just sitting there in the infusion clinic, and they can easily engage with the dieticians. OK, great. And my second question was just for your therapists. I know we have not many with specialized cancer training. And so I didn't know how many of your physical therapists, occupational therapists, speech therapists do a certain extra training, like summit or something else that you're aware of? So I mean, at my institution, we do have, I guess, a subset of physical therapists, at least, that are specialized in cancer, mostly breast cancer. And then we have specialized speech therapists. But they mostly work with the head and neck population. So I would say short answer, yes. Larger answer, general, nationwide. The only thing that I'm aware of is revital by select medical. So we utilize them a lot. I think they're growing. I thought I saw Dr. Stubblefield here somewhere. So maybe ask him. But that's the only national one that I'm aware of. Thank you. Good morning. Thank you so much for a great talk. I wanted to, along the lines of your comment about decreasing the number of appointments, I wanted to see from a practical standpoint what your recommendations about starting an SSRI. When I see some of these patients where I feel like they really need one, I look. If they're already on something, I see if it's a PCP, or maybe they're already followed by psychiatry. So that's easy. But where there's really nothing, I guess I have a hard time starting, because of interactions. And within, it's such a big group of medications that it's hard to, and they have different side effects. And I think it is pretty specific which one is more appropriate for which population, or which person. So I wanted to see your suggestions about any ones you typically start with that are kind of easy, and then if you think they need more, then you can refer. So you're not either going to palliative care right away or going to psych right away. Yeah, no, that's a great question. Thank you so much. So I'm not a psychiatrist, but I do prescribe a lot of SSRIs. And thankfully, we just had our didactics yesterday for one of our cancer psychiatrists who was talking about this exact issue. And I think probably what you're talking about is the potential interaction with tamoxifen and SNRIs. So particularly like Effexor or Cymbalta, everybody's worried that that will decrease, because tamoxifen's a prodrug, and that'll potentially decrease serum concentration of tamoxifen. So basically, you just want to avoid SNRIs. But she brought up one study that shows that it hasn't actually been implicated in actual cancer recurrence. And I've looked this up, too. And in my brief literature searches, I wasn't able to find anything indicating that even if they were on it, that there would be any kind of potential risk of recurrence. So I would say that maybe the concern is a little bit overblown. But if you're just looking for the one-word answer, Lexapro is pretty safe. And yeah, five milligrams of Lexapro. Thank you. I mean, I guess I was looking for that. But also, I think some are a little more for anxiety. Some can cause weight gain. Some actually decrease appetite. So like Wellbutrin, for example. So I guess I was just thinking of that. But that's useful. Yeah, or I mean, yeah. I would say, so yeah, definitely one of the other cancer rehab docs I work with, he does a lot of this, Dr. Rosh Asher. But I'm going to say we frequently prescribe Effexor, Wellbutrin, and Lexapro. And kind of like you were saying, it just depends on their symptoms. So if somebody has increased anxiety or we're worried about a manic episode, then we might avoid Wellbutrin. But if they're really concerned about decreased libido or they have ongoing fatigue, which Wellbutrin has been shown beneficial for, then we might go in that direction. But if it's just like dysthymia or depressed mood, then yeah, Lexapro or Sertraline or something. OK, thank you. Any other questions? I'll look online. I don't think we've got any online from there. But I wanted to ask Neil, what would you say is the ideal referral time for someone to be referred to you? I think immediately. If you notice that they're having any pain and it's limiting your ability for them to go through their rehab protocol, you want every possible person involved. I kind of always tell people, especially when it comes to medications, when you think about pain, people are always like, what's the one medication that I can take to try to solve all the pain? And obviously, opiates are useful, but they have drawbacks. And I always kind of tell patients, you want to do multiple different things from different angles, a muscle relaxant, anti-inflammatory. The same thing is to be said with all the services that we offer. Having supportive care, having rehab, having psych, having social work, having all of these things is useful. And I think, obviously, we talked about having too many appointments and things is bad. But the solution, which every one of them had mentioned, is trying to stack these things at the same time, having things happen at the same time, and piggybacking off of the oncologists and their treatment plans. And that's the hard thing about cancer in general, is that trying to coordinate all of this and make it easier. So if the patient is in any way struggling to do the things that they need to do, if they're struggling to do chemotherapy, radiation, their rehab, that's an indication to send them over and see if there's anything interventionally that can be done to make it easier for them to do that. Thank you. And then if I could ask Phil as well, is there a certain KPS score or change in KPS or something along those lines that we should see as a red flag and refer to the palliative or supportive services at our institutions? I'm gonna say an ECOG of three and a KPS of 70. Those people probably should have been referred a while ago, but these are also very subjective scores. Like you're asking an oncologist who's trying to recruit somebody to do their study, they're just gonna be like, ECOG one. Person's ECOG one. So it definitely just depends on who you're asking. But I would say, yeah, if they're saying like, I'm gonna say an oncologist ECOG of two or a KPS of 80, yeah, I'm just spitballing here, but yeah. And can I ask Hannah, I know that you work with some people that live far away from the Seattle area, maybe even in Alaska. What are some tips and tricks that you have when working with patients in the knee cancer rehab, but resources are limited? It can definitely be challenging. So in Seattle or at Fred Hutch, we cover the WAMI area, which is Washington, Wyoming, Alaska, Montana, and Idaho. So we see patients that make a trek, especially for supportive care services. And I think that initial visit or stacking visits when patients fly in and stay in the area is really key, even if we don't anticipate need, but sometimes we will have patients stay the day to see our physical therapy team, even if they haven't had a positive screen, but the oncologists are great advocates for anticipating what needs may be. And then we've partnered with community sites or community practices in those states where we know that someone has even an inkling or interest in oncology care and really tailoring and making sure patients are advocating for the precautions that we are counseling them on, as well as, yeah, do's and don'ts of things to look out for in physical therapy. I think our therapy and lymphedema therapy colleagues have also been, definitely go out of their way to try to communicate and collaborate with those community providers to tailor that exercise prescription or rehab plan. Yes, thank you. Well, thank you very much, everyone, for coming. I think we're at time. I think it was 1045, so we're at time. But I really appreciate you coming and working with this patient population that can be very rewarding but challenging at times, as well. And thank you very much to the panelists, and I hope you have a great day, as well. I was supposed to make some announcements earlier about picking up your T-shirt and things like that, but I forgot. But thank you very much for coming, and thank you guys. Thank you.

cancer rehabilitation

palliative care

cachexia management

interventional pain management

holistic support

personalized treatment

interdisciplinary collaboration

electronic patient-reported outcomes

GDF15-targeted therapies

quality of life

supportive care resources