Okay. Good afternoon everybody. Thanks for joining us on a Saturday afternoon. We are talking about overcoming multifactorial challenges of providing rehab to cancer patients. I'm lucky to have a couple individuals with me speaking today. Dr. Laura Wong to my left. Dr. Diana Molinares has been a critical part of today's lecture. She had a wonderful addition to her family about a week ago, so she sends her regrets not being here. And then Dr. Amy Ng to the farthest left. So we'll get rolling because we've got a lot of content to share. So just a few very brief introductory slides that you may all know already, but the cancer prevalence of patients is obviously going up. We have wonderful cancer care being delivered, so patients are living longer and thus we have a higher prevalence of cancer patients. The different colors are just based on the ages of our cancer patients. So you can see from red going up, red is 50 to 64 ages and then on up the increased ages of patients. I don't know about you all, but I'm seeing a lot more patients less than age 50 though too. This slide, another demonstration just of the number of years post a cancer diagnosis that patients are surviving. And as you can see, obviously that's increasing as well. The red bar is essentially living one to less than five years post diagnosis. And then above that, greater than ten years, green, purple, and blue, those numbers are exploding. So we have a lot of cancer survivors to serve. Getting into just the rehab part of that, our adult cancer population has a lot of rehab needs. We're not talking about peds today unfortunately, but just adults with rehab needs. About a third of our cancer patients have difficulties just performing their ADLs alone. And then up that to about a half of them have a hard time doing their IADLs. And that really impacts their ability to receive rehab care. Just walking transfers, housework, getting out of the house, it's difficult for these patients to receive rehab care. So how many cancer patients, real briefly, have rehab needs? About 60 to 90 percent of our cancer patients have some form of rehab need, but we aren't getting those patients served across the nation. There's various studies showing how many patients are getting rehab needs addressed. It's anywhere from, you know, two percent or less than two percent to less, definitely less than ten percent though. So I'm going to hand it off to Dr. Wong for the next several slides. All right, thank you Dr. Nelson. So I wanted to give a special shout out again. I think she's worth giving two shout outs, is Dr. Diana Molinares, because this project is, you know, the product of her tireless efforts, which she does on top of being the Director of Cancer Rehab Medicine Division in our department, and then the Cancer Rehab Fellowship Program Director, and the Residency Associate Program Director. So let's give her a round of applause. Okay, so what I'll be presenting on is the use of a clinical workflow to facilitate care coordination and access for patients to cancer rehab services. So we received funding for this project from the Florida Department of Health. So as Dr. Nelson was saying, the incidence of cancer is rising. So this is for 2020, or 2022, we will hit approximately almost 2 million patients with a new diagnosis of cancer. As of 2019, there were 16.9 million survivors living, many of them with cancer in the remote past. By year 2040, we're expected to hit 26 million survivors. So that number is disproportionately growing over the incidence, likely because of innovative new treatments that are leading to longer life expectancy, even for patients who have metastatic disease. So cancer survivors have unique needs that need really an individualized and sometimes multidisciplinary team approach to help them build up to their new normal. So how do we get there? How do we connect these patients with the right service at the right time? So unfortunately, we can't see everybody. So we took a risk stratification approach to try to focus on the smaller group of individuals at the top who have more complex impairments and needs, and the larger groups with less impairments or needs to manage that with education and other support services. So our clinical workflow to facilitate care coordination and access to cancer rehabilitation services was a joint effort of the Florida Department of Health, the University of Miami Sylvester Cancer Center, and the Department of Rehab Medicine, and our Cancer Division. So why is this important? Multiple organizations, national organizations, have released recent guidelines indicating the critical importance of having rehabilitation for a cancer survivor. However, there's no implementation guidance of how and when to refer these patients, in a way limiting patient access to these services. So historically, cancer rehab began gaining increasing recognition in the 70s. Other identified barriers were that there just weren't enough cancer rehab medicine providers at many cancer centers. Also, that patients were being referred when they were too ill, or the patient denied their need or didn't have enough financial resources. Another barrier is the lack of awareness of rehabilitation services by referring providers, which leads to under-identification and absence of referrals. So the goal is to determine the implementation impact of an evidence-based best practices clinical workflow to facilitate care coordination and access to cancer rehabilitation services. So these patients are identified through the Cancer Center electronic medical record system screening tool that they already had in place called My Wellness Check. So first, I'd like to give you the background. So My Wellness Check is a tool that was in place at the Cancer Center about a year ago that they started it. So the way the tool works is when the patient is scheduled, they're identified based on their ICD-10 diagnosis code. And then three days before the appointment, the patient portal system will send them a message to complete a battery of patient reported outcome measures. So this also assesses for social and psychological distress, nutritional deficiency, and then the physical function. So if the patient doesn't complete it 24 hours before the visit, the social worker will give them a call. And then if it's still not completed, the nurse in the clinic will help them finish the assessment. So at the time that we took on the project, the only functional measure being assessed was the PROMIS functional scale. So patients who scored only a score of less than 30, indicating severe impairment, would generate a prompt for the care team to refer to Cancer Rehab Med. So to assess our efficacy, we first wanted to get baseline data. So baseline data of what was already in place of patients who completed this physical function assessment between June and December 2020. So of those 1,772 patients, 182 of them, or 10.3% of them, scored less than 30, which triggered a best practice advisory for the oncology care team to place the referral. So we estimated that this number was low, and we wanted to see if it was an under-representation. So our objectives are to successfully implement an evidence-based clinical process in conjunction with the existing My Wellness Check, to use data to promote the use of rehab medicine in cancer survivors by guiding state and federal initiatives and policy guidelines, identify the volume of survivors that would benefit from these services across the cancer care continuum. So how do we do that? So what we did is we used the 2019 American Cancer Society article, Exercises Medicine in Oncology, Engaging Clinicians to Help Patients Move Through Cancer. So the screening tool assesses three things. So first, is the patient exercising? Are they doing aerobic exercise? Are they doing strength training? And then the third question is, are they safe to exercise alone? If the answer is yes, and this is usually in patients who are ambulatory or have an ECOG of 0 to 2, they would be, they would receive education as well as referral to the best available community program. If the answer is no, or the provider isn't sure, then this would advise them to educate the patient and make the referral. So again, this is the existing process up top, this top area that we saw on the other slide. So what our project did was it augmented the My Wellness Check to incorporate two questions for the patient, one question for the physician, as well as create a mechanism to provide education resources to the patient electronically. So where it all comes together, so the patient's at home, they have their appointment tomorrow, they log into their MyUHealth chart, and so as after they complete the other questions, they'll answer if they've exercised three or more days in the past week with getting their heart rate elevated, and then they'll answer, did you perform at least two days of strength training this week? If they say yes to both, then no further intervention is needed. If the patient says, I'm sorry, if they say yes to both, if they say no to both, then this would send a best practice advisory in the EMR system to the oncology care team providers to ask if the patient is safe to exercise unsupervised. If the answer is yes, then they just get educational material or a referral to a community program. If they're not safe, that would trigger a referral to cancer rehab. So I have some preliminary data to share. So since implementation of the project over about a six-month period, there have been a hundred and seventy-seven patients who have completed their MyWellness check and their providers have placed the referral to Cancer Rehab Med. So the average age was 65, ranging from 26 to 96. The gender distribution was fairly even. The respondents were predominantly Caucasian, about 40% Hispanic, and then most of the insurances appear to be commercial or Medicare. This is the disease groups represented by the patients who were referred. One thing we noted was that the breast nervous system and GYO cancers were, their numbers were a little bit low, and our hypothesis is that we, anecdotally, we think we have a good relationship with those service lines. So we think that they might be getting referred even before the MyWellness check. So from this patient population, the original PROMIS function scale that existed before we stepped in was 268 patients that it identified as having functional needs. Adding the new tool, the Physical Activity Best Practice Advisory, that actually triggered 664 alerts that these people have functional needs. So we, you know, so we're interpreting that to mean that it's a more sensitive tool at assessing physical impairments and limitations than the PROMIS physical function. So the other thing we noted about this data was that the Best Practice Advisory was being sent 602 times, yet only two patients got the education package, and then 421 of those advisories were canceled. So we see that as an opportunity to provide more education to the oncology teams. So in summary, this project will help guide best clinical practices and establish a much-needed standard of cancer care delivery process specific to identifying physical rehabilitation needs and triaging patients to appropriate services. And that's our contact information, and then I have a shameless plug. We have a fellowship spot that's open, so if you or you know someone who's interested, please come see me. And then next we have Dr. Amy Ng. Well, you know, we originally thought about this lecture as talking about barriers and access. We heard a very good talk just about how to try to decrease some access barriers for our patients. In this next section, I want to focus on the cancer patients themselves. What are the barriers our cancer patients are facing in achieving the goals of exercise and things that we are telling them to do that will help them? So I'm Amy Ng. I'm from MD Anderson Cancer Center, and follow me on Twitter, shameless plug. Thank you guys also for coming to our talk. I have no disclosures to report. First, before we start, I would love for you to try to participate in this poll. I hope it works. Keep your fingers crossed. This is going to ask you a question just about your exercise and how much you do, and I'll give you a short minute or 30 seconds. Is anybody having any trouble? We can all do it? Okay, great. You got it? Okay. So, did you exercise for 150 minutes in the past week and engage in strength training for two times or two days of the week? That's what we try to tell our patients. And I even left out the part about moderate aerobic activity. I will let you count walking back and forth, you know, from this sky bridge over here. So, as we can see, like in this room, we have, we ourselves sometimes can't practice what we preach. Although, I do tell patients, I do as I say, please don't do as I do sometimes, you know, life gets in the way. And so, as you can see, with our own healthy population, we have room for improvement as well. Let's see, there should be a second question. And I want to know, and even if you did do 150 minutes in your strength training, I do want to know, like, what thought went into your head for those people that answered yes, they do. But what thoughts clouded your head to maybe say, oh, let's not go to the gym today or let's not walk outside today. And then for those who answered no in the previous slide, just tell me what words come to your head, like why you were not able to do that. Yeah. Absolutely. Kids. I see work. I see kids. I see family. Yeah, so we ourselves are doing, you know, we ourselves have lives and doing what we need to do to try to adhere to these recommendations. And really, in this talk, I want to focus on our cancer patients and see what kind of barriers they themselves are facing. So just a little bit of background, because this came up from a reviewer, what was the definition of physical exercise or physical activity? Are we looking at exercise or are we just looking at any movement in a part of our body? So we just took, we in fact had to change it to physical activity because we're counting any kind of movement for skeletal muscles, although we do tell our patients to perform some kind of exercise, which is a planned activity that's structured or repetitive and things that you have an objective to try to improve. So we, I think we all know about the link between exercise and cancer, a strong link between decreased exercising for some of the cancers and then a strong link between body fat and increasing cancers and these other kinds of cancers. We've already talked about the increasing risk factors, the deaths that are attributed to cancer. So what we have been advocating through the years is really to promote this exercise, exercise, exercise, exercise. And then recently, I've heard a lot more like moderate intensity, moderate intensity, you got to do moderate intensity. What is moderate intensity? And then there's even some talk of vigorous intensity, which was great for us, but can our cancer patients meet this recommendation that we are throwing out at them? So of course, a lot of things that we sometimes don't know ourselves, but cancer-related fatigue, side effects from chemotherapy, radiation, surgical treatments, a lot of ADL impairments maybe from surgery, and overall, just population-wise, how many people know that I should be exercising 150 minutes moderate to vigorous, you know, moderate intensity or 75 minutes vigorous intensity? And what is that intensity, right? So we got to take these factors into effect and those are some of the challenges that cancer patients are having to work with. So the guidelines that we are currently recommending is some kind of combination of 150 minutes of moderate intense aerobic activity, two to three, and two to three weekly sessions of strength training, at least two. We have also been talking about, like, cautions and, you know, precautions and things that you should take into consideration when recommending some of these programs. Earlier talk with Sean Smith and Sarah Park mentioned, you know, about some precautions, platelets and stuff like that, hemoglobin levels, fatigue. So things that other doctors are recommending or even oncologists are recommending are also adapted into some of the recommendations we ourselves can be showing to our patients or giving out to our patients. So in 2010, I think this was the first talk about what can cancer survivors really safely do and starting to put out papers in 2010. Prior to that, there might have been a lot of literature and a lot of talk from people about, you know, maybe cancer patients shouldn't exercise or maybe they should, you know, take it easy and rest while you're getting chemotherapy. You don't want to tire them out too much. Or perhaps, you know, while they're getting chemotherapy, you might do more damage. So throughout the years in this past, since 2010, then there's a 2018, a second round table convened and Campbell et al. came out with the exercise and consensus statement from this multidisciplinary round table, which is what I had mentioned earlier. And a little bit more specific cancer types, treatments, and our outcomes. So what we're trying to tell everybody is exercise is beneficial. Exercise can help you overcome these side effects of chemo brain or reducing your cancer-related fatigue, help you get some muscle mass back, and overall, just change your lifestyle as if, you know, you are currently done with your cancer treatment and continuing to live your best life. Plus, we know that there's some other benefits to heart, lungs, other emotional anxiety, depressive symptoms, overall quality of life, and physical function. So in all that, we know all that, but I really wanted to see what was going on in our clinic, our cancer patients themselves, and what are we seeing? So again, I asked the same questions that I asked you to our cancer patients. I wanted to see how many cancer patients that we're seeing are actually engaging in physical activity. And then I wanted to know, I know what my barriers are, but what are your barriers? Why couldn't you do the things that I'm asking you to do, and then you come back to see me and follow up, and you tell me I did none of that, right? So that's what I wanted to do, because I wanted to change their thought and, you know, how we can, what is it that we can do to help engage them? And were there any associations to these personal barriers that they were having to, you know, to the physical activity recommendations? And were there any subgroups of patients that might say that they really had a hard time doing the exercise recommendations that we were giving? So we obtained IRB approval, we ended up with, we recruited 200 patients, and what I mean by new patients is like new referrals, consults to me, never seen in our clinics before. And then the returning or follow-up group, 100 patients. They had to be over 18 years old, our clinic only sees adults, we don't have any children. They have to be able to read, write, and speak English so they can interact with the forms. And they were able to sign consent and previously not have filled out any surveys such as these before that we were getting them. So patients, we did, we did, we could not enroll patients who were either bed-bound all day and wheelchair patients I was okay with, but the ones that were in wheelchair or spent like the majority of the day like not being able to exercise or not being able to move around, bed-bound patients, or those with a lot of physical distress were not ineligible. They were either not enrolled or withdrew from the study. We used this adapted barrier scale from Rogers et al. treating breast cancer patients and she actually did some head and neck cancer patients as well. She wanted to know about barriers in social cognitive theory. And so some of these barriers are lack of interest, self-discipline, lack of time, company, enjoyment, equipment, weather in Houston or Chicago for example, no facilities, maybe they're having pain, injury, cost, nausea, symptoms such as nausea, fatigue, or they just found exercise was very boring, procrastination, or what their thoughts were about exercise not being a priority, boring, or family responsibilities, or just exercise is not routine. So patients were allowed to pick one, two, all of them, whatever they wanted as the cause of why they didn't exercise in the past six weeks and they were asked to rank how often these barriers affected the ability for them to exercise in the past six weeks from one never to five very often. And so we were able to count the number of barriers as well as associate like how heavy this burden weighed on them, this barrier was a burden to them. We also took a short promise form and we asked them whether they had any difficulty or no difficulty in being able to do some of these questions or some of these activities. Our promise short form we use, I know that sometimes it is kind of hard, like I think one example was about, I thought it was here, two miles, you run for a fast pace for two miles, you know, some people are just like, I can't even run. So you know, that can be kind of hard and some healthy people don't even run or some people, some healthy people just walk, you know, so that could still be misconstrued and a little bit, but some patients did, they did their best to answer this one. And we also asked about, we used the ESAS to ask about their symptoms. So pain, fatigue, nausea, depression, anxiety, drowsiness, appetite, feeling of well-being, shortness of breath, sleep issues or financial or spiritual distress. In our demographics we had about, we had mostly females, about 55% were females, our population at MD Anderson is majority white, I was not surprised, so it was about 78% Caucasian, most were well-educated, graduating college. We did have, we had a lot of diagnosis, cancer diagnosis, we see everybody, but just for the sake of brevity and not to fill up the entire slide with the type of cancers, you know, I just highlighted the top three. We had some GI, breast and head and neck cancers and then we had, most of the patients had 53%, 54% had metastases, we're seeing a lot of advanced stage cancer. We do partner with supportive care for some of the clinics, so we see a lot of patients, you know, throughout our clinics that may have been seeing supportive care as well. So we recruited both supportive care and also rehab patients. So about 70% were advanced stage breast cancer, I'm sorry, advanced cancer stage 3 to 4. Just a summary of the findings, again, I wanted to know before they came to us or returning patients, we were able to separate out the groups, how many of the patients were told by any MD Anderson physician, any physician, that cancer, that exercise would be beneficial for them. And so we had a pretty resounding yes, they knew, like 171 patients are 86% new and among new patients or new consult patients, 81% new. And among returning patients, 90% new, there were some significant findings in that. And then looking at the number of active minutes, we asked them how many, we went in, we tabled how many minutes that they reported that they did. So they had a tally of how many minutes in the past week and so they circled, you know, how many minutes they did. And so among all patients, we were able to get about 130 minutes of exercise and then among new patients and new consults, about 108 minutes and then among returning patients, we got up to 150 minutes and there was some significance. So just a summary of findings of their main findings among the new patients, the consult groups. We also stratified, because 150 minutes to a cancer patient, if you just say 150 minutes, it sounds like a lot. So, you know, we also looked at the group 60 minutes, okay, were you able to achieve 60 minutes. So we broke down that as well, about 60 minutes or 100 minutes or less than 60 or less than 150 minutes. So in red are really like the barriers. So the number of barriers and the more number of barriers that they listed and the checking more often resulted in the fact that they were not able to achieve the recommendations, either at 60 minutes or 150 minutes. So with one unit increase, that means if you just gave one extra barrier, you listed one extra barrier, you ticked it, that was almost a 17.5 less chance that you reached 60 minutes of exercise. And if you, and one increase in your barrier was 18.4% less chance that you would achieve 150 minutes. Now the PROMIS score was the function, so how much function could they do. So in terms of the function, if they were able to do more things in the function, they answered just one more thing that they could do in the PROMIS scale, then there was an increased chance of 8.8% that they would achieve the 60 minutes. So again, the last sentence was just talking about the number of barriers. So among new patients that we just started seeing at first, they were the patients that said that they achieved 150 minutes, they only had 2.6 barriers, but the patients that said they had less than 150 minutes or didn't meet our recommendations had 4.2 barriers. Among follow-up patients, again you kind of see the same thing, but interestingly follow-up patients actually found that females were less likely. Being female and having ESAS score with anxiety or pain or well-being, they were associated with a less chance of achieving 60 minutes of exercise. And then among the barriers, patients that reported that they really enjoyed it or not lacking the enjoyment, they were associated with 60 minutes, more likely to achieve the 60 minutes. And then often if you didn't complain about fatigue and you had a higher PROMIS score, you were more likely to achieve the 150 minutes. And interestingly, you know, all the other barriers, like of course I think it's what we expected, the less barriers you're complaining about or checking that you're having trouble with, the more likely you'll achieve 150 minutes. Interestingly, we also saw like when they did come back for follow-up, we saw that patients were more likely to report less fatigue, anxiety, a worsened well-being, and sleep. So somehow in that time frame from the first time we saw the patient to the time they followed up, they reported less of these symptoms. In amongst all patients grouping together the new, grouping together the follow-ups, we see again females, the higher number of the barriers, and then a rating, a poor well-being rating would have less chance to achieve 60 minutes. And amongst the 150 minute group, if you had a higher PROMIS score, you were more likely to achieve. And if you had higher number of barriers, marking number of barriers, you were less likely to achieve that 100 or 50 minutes. So putting it all into our practice, how does this translate? This is, what do we tell our patients? So again, we recommend 150 minutes of exercise. Can you break this up into 30 minutes, you know, three times a week, five times, three to five times a week. Can you do 10 minutes, three times a day is sometimes what I recommend to the patients because they're not able to achieve a 30 minute all in one session. I tell them 10 minutes, three times still counts. You can check that off your list, you know, and even if you wanna break it up some more, you can do that. But as long as you total 30 minutes, most days a week, I'm happy. And then we talk about like how much strength training, you know, to do, we give them a set of body exercise, body weight exercises to do and try to check off some days that you're doing some strength training as well. So overall, I think we had our patients reporting, engaging about 129 minutes of physical activity prior to coming to see us in clinic again. And we were able to break this down amongst the new patients and the follow up patients. So talking about barriers amongst the new patients, what can we tell these patients or what are you gonna look for when they come to you as a first time patient? So if they report any barriers or if they talk to you about, you know, just they're having a lot of fatigue, for example, or they're feeling very emotionally drained, overall, just not feeling themselves and not being well feeling. Of course, you know that you are at risk for not achieving any of the exercise recommendations that you're giving to the patient. So each thing that they might tell you, you know, indicates a little bit more and more trouble that they're gonna have to adhering to your recommendations. So identifying some of these barriers early and problem solving with your patients is very important. Again, for all patients, you know, finding out what do they like? What makes you happy? What is it that would get you outside or get you to walk from even your house, outside of your house, you know? What is it that you like to try to help them prevent boredom? Do they, some people hate running. They only like to walk or some people really don't like to, you know, go to the gym. So finding these things and trying to change and telling them that it's okay if you don't like to run. Not everybody has to run. Maybe you can do something else and finding that joy again and helping them to find joy. So of course, touching on some other things that we should consider. We know that cancer related fatigue is one of the big barriers and what previous studies have shown is that if we can just engage in the exercise, we can really tell our patients, I know you're really tired. I know 30 minutes sounds like a lot, but if you can just, when you feel tired, just stand up and walk in your room. Do five circles or wherever they are. Go outside and just walk up and down the driveway. You're gonna feel a little bit better. You're gonna feel that energy come back. And I'm laughing because I see some people yawning. I'm like, you should get up and walk. So we also know that increasing the strength training, we can put some muscle mass back on you. On our cancer patients, which helps them with cachexia and sarcopenia. And then these two things that we know are associated with decreased tolerance to chemotherapy treatment and also to treatment and also to increase in mortality. So we can tell our patients, hey, if you can do just two days of simple sit to stands, going from here to here and strengthening these quad muscles, you're really gonna help with building some muscles back and achieving these goals that your oncologists really want you to have. So again, those who were reporting that they were not having fatigue symptoms were more likely to adhere. So if we can fix the fatigue, then we can get them to adhere to our guidelines. I'm gonna skip this slide. So also, I talked about the female patients, female groups of patients who were less likely to adhere to our guidelines. And I don't know if it's like family or if it's females might have more burden associated with their inability to do more for themselves, let's say. And so finding out what it is that we can do for female patients, adhering and doing some interventions, tailoring interventions for female patients so that they could get to adhere to exercise or maybe just validating, hey, I know that you have a lot on your plate, you're taking care of your kids and you've got a job, but maybe just take time for yourself and letting them know that it's okay to take that time and just work on themselves. And just something as simple as that statement could help them achieve a little bit more to our guidelines to exercise more. For new patients, we talked about the promise, how functionally, if they were able to do more function, they were more likely to engage in the 60 minutes or 150 minutes. This is where I think our rehab docs can really make a difference. If we can prevent their decline, if there's things that you can warn them about in their treatment, upcoming treatment, either with chemotherapy or with radiation, things to look out for. And tell them, if you experience any of these things, come see me, I need to see you back if these things happen to you because we actually need, we can do something about it, we can help you. And not just telling them to go walk around the block, but if there's impairment in their shoulder or an impairment in their knees or back brain, I mean, all those things are bread and butter and we can really do things to help them not get impairments so that they can do more physical activity. Also in our clinic, I mentioned earlier, we were seeing some of the more advanced cancer patients. So checking, just being able to see that these patients really, who saw a rehab physician, they were more likely to adhere to at least 60 minutes. They were more likely to be able to get that 60 minutes. And then, of course, as we all know, getting to the patients early before their intervention, either in chemo, surgery, or radiation, we can make a difference with a prehab intervention and that's something else to sell to our oncologists as well. Earlier there was a session and there was a question about metastasis. Because we're seeing advanced cancer patients, we do see a lot of patients who have metastatic disease. These patients have been told all their life, or maybe once they got diagnosed with METS, they were very scared. I don't know if I can do this, maybe I can't. There's a lot of misunderstanding too. What can we do and what can we not do? And so overall conclusion is that we know it's safe for cancer patients to exercise and a lot of studies might put some fear in patients about if you have a MET, maybe you have to be bed bound. But we're finding more and more that we're not telling our patients this anymore. So even if you have metastasis, we still want you to exercise. We still want you to continue to do some strength training. So we should be careful though. We know that there could be some precautions we might recommend. For example, assessments of their strength. Maybe we don't want to put all their weight on the leg that has a MET in there and not do the single leg press to avoid certain movements and strength testing. The movements that we like to avoid and excessive high loads on skeletal sites, high impact loads, hyperflexion, hyperextension of the trunk and then added resistance with dynamic twisting. So the further out you're lifting weights, you're lever arm and you're just putting a lot of pressure on the skeletal load. And so we do add that modification and try to tell that as a precaution as well to our therapists as well as to the patients. Overall, we also caution about falls. We want them to be aware and the number one thing I say is like prevent falls, but how do you do that? Things at night, nighttime is the highest risk for falls. So I tell my patients, please if you have to go to the bathroom, make the walker accessible or if you know that he or she needs assistance, you sleep on the side where they can't get out of the bed without actually touching somebody or having to alert somebody. So and just for our providers, we should be aware of any signs or symptoms like increased pain that wasn't there overall yesterday or after therapy, there's some increased pain. Common sites and location where METs could occur so that if their patients are complaining of certain pain, the first thing you do, you're gonna get an image and notify their oncologist. So and finally in discussion, how do we get these patients to adhere to our guidelines? And that's an important thing. What I say to the patient next time they come see me, do they do these things or six months down the road when they come back and see me again, are they still doing the things that we had recommended? So that's a good, we wanted to know that question again and in our study, we had 34% of patients who were reporting adherence to the guidelines of 150 minutes. In the US, the average was about 23% of adherence and those were age 18 to 64 and reported meeting those guidelines and this was just all US adults, so not even cancer patients. So I think that we are doing a good job with providing the recommendations and trying to problem solve and providing the follow-up visits to make sure that they're adhering to the guidelines. It does remain a challenge, I think, for a lot of patients, a lot of practices. So in other cancer populations, another study only reported about 8.5% in the head and neck cancer patients who were actually adhering to the 150 minutes and so perhaps this is a group of patients, perhaps it's most likely, I don't know if they had follow-up with rehab doctors but this is somewhere where we can get our foot in the door and help increase the adherence for other cancer groups as well. Again, following up referral for PT, OT and DME needs and addressing their symptoms and then also looking at the settings. So again, we know that enjoyment and knowing that if they enjoy something, they don't find something boring, we're more likely to see them adhere. So do they need somebody to watch over them as they do their exercise? Some people like that. Some people really feel that the therapist watching them and giving them guidance is what they need versus some people say, I don't want that, I don't want somebody looking at me, I don't want somebody touching me, I'm afraid of COVID, I'm in a compromise. Okay, so they can do their own home exercise program, here's your packet, here's your exercise, I'll follow up with you and virtual visit, we can check on, see how you're doing. And then future studies, we want to know, you know, how can we integrate some of these wearables or technologies or telehealth to try to continue to see how they're adhering to our guidelines and recommendations. As I mentioned, if they're not able to come back and see you, you can do a virtual visit and kind of check on them or a telephone visit or perhaps any other technology that you might think of. So how do we engage them into their enjoyment, interest in self-discipline, you know, finding routines that they like, as I mentioned, things that they like, ask your patients, they want to talk, they want to tell you what they like or dislike and then trying to come up with a plan, like how can we make this something that you would really like and you would really do and come back. And so sometimes I even talk to the patients about why don't you walk with your spouse, you know, or why don't you call your daughter while you're walking, you really wanted to talk with somebody and your daughter's on the phone and they're telling you, go dad, you can do it, stuff like that. And, you know, if some of the trackers, pedometers, some people like to see how many steps, how many minutes that they're using, that they're doing and performing and some people will come back with their chart and say, you know, I did 150 minutes, here it is, Dr. Ng, you know. So whatever it is that you can get them to adhere to, enjoy, I think that's a way to get them to adhere to our recommendations. And finally, I just want to say in, I know this talk is not about, you know, how do we get everybody to be able to tell the patients, but if you, because this talk is more focused on barriers in our cancer patients and how do they get to the exercise, but this article that came out really can help general physiatrists, other physiatrists that might not be doing what we're doing to help patients. It doesn't have to be cancer patients, but I think integrating it into your practice so that you can tell patients how to do the exercise and different, it'll have like different graphs that you can show and figures for patients to understand a little bit more. So that's it today. And finally, I'll turn it over to Dr. Nelson. Thank you. myself, so thank you for the permission not to have to run because I do not like running, but I enjoy walking. I did not meet my 150 minutes this week, unfortunately. I try, I really try, but I work at University of Louisville Health and Practice Cancer Rehab and we've talked a lot about barriers today, barriers to exercise, and there's barriers just to getting to a rehab appointment to PT, OT, speech, so I feel like Dr. Ng did a great job of like what are some of the internal barriers as a patient restricting you from feeling like you can accomplish that rehab or exercise task, so what my slides are gonna focus a little bit more on is awareness of cancer rehab, not just from the patients themselves, but from our own health care providers who don't fully know what we do right. Another big barrier, especially when you're coming from a state like Kentucky, which has a lot of rural areas, not as many urban areas, not everybody lives in Louisville, Kentucky or Lexington, Kentucky, so how can we get cancer rehab to these patients? Transportation is a huge issue. Even when you maybe have the financial resources still, you may live a long distance from some of these cancer centers. Social support, do these patients have the social support they need to get what they need? And the bane of our existence, insurance coverage sometimes, but so I just want to talk and share a little bit about one way that in the state of Kentucky we're trying to work on awareness efforts of cancer rehab. This is a group of individuals that we've been working together over the past about year and a half. Audrey is the second picture right next to me. I know I look different. I changed my hair color, you know, here and there, but Audrey and I kind of came together and we're from different institutions said this, how can we get cancer rehab to everybody? What do we do? So our mission in our cancer rehab across Kentucky, we now have that little imagery which we're really excited about, but the mission is for cancer patients in any Kentucky community to have access to and choice, choice is a big key too of quality rehab care to assist with these functional needs that we know exist, whether you're going through cancer treatment or you're beyond cancer treatment, all of the above. So our vision, kind of three key steps. We said how can we create and expand a central access point for any Kentucky patient to identify quality cancer rehab providers. So I'll answer that question in a second. Our goal is to empower patients to choose. You know, they get seen within a system and the system, what does the system do to us? They keep it within the system. But how can we say no, you have choice of where you go and you don't have to come to the cities to get what you need. And how do we educate rehab providers beyond our urban areas and get into the rural pockets of our state, which is more than the urban areas. So it was really exciting cancer rehab across Kentucky. We have no funding, zero. It's just a group of individuals that say we want to try to help patients at large. So we partnered with Kentucky Cancer Program, which is a state funded entity that has kind of a central website that says, hey, these are some resources for you cancer patients wherever you may be. And I encourage you all to look within your state, what are some state funded institutions or organizations that could partner with you to make things free for yourself. So patients can go to this website called the Pathfinder if you live in Kentucky. You can click on your county. And we've helped identify rehab providers across the state. And we start having them add their credentials to the website. This has taken a lot of work because obviously we had to get institutional buy-in to say, hey, your providers are going to be on this centralized web page that isn't your web page. So we're working one institution at a time. So that's one just idea of working within your own community and state. Transportation is a big problem. Cancer treatment is expensive. And transportation has become super expensive. Gas prices are a little bit down now. So what have we done within our institution? I work with Brown Cancer Center. It's kind of a small academic cancer center. I'm privileged to be part of the wellness mission, which is called SOAR On. And it stands for where strength and opportunity for all are realized with oncology. We work with a safety net hospital. University of Louisville is a safety net hospital. So we have patients who make less than $30,000 as a household often. So how do we help them? The SOAR On program is actually a donor funded program. And one of our main goals is to make sure transportation is covered and lodging for our patients, because some of our patients come from over 100 miles away to get treatment there. And just our 2021 data, because we don't have a 2022 data yet, but half of our donor funds go to just getting patients to and from cancer treatments and paying for that. So working with your cancer center and figuring out what free resources they are able to provide is super helpful to helping them get their rehab needs, too. So we also give out cast cards. We give public transportation tickets. But what if that doesn't exist at your institution? Again, partnering with your public transportation to see what they have available. Public transportation is helpful because they also have handicapped accessibility. Unfortunately, you know, the typical Ubers, the typical Lyfts that you may utilize don't have wheelchair accessibility. But there are a few, of course, they've got to be big cities in our country, do have what's called LyftWave, W-A-V, or UberWave, W-A-V, which is just wheelchair accessible vehicles. I hope that expands, but keep your eyes out for that for maybe you live in one of the cities that has those available to you. Utilizing national organizations is another one way to help your patients get transportation. American Cancer Society has a program called Road to Recovery, and these are volunteer drivers, volunteer drivers who will go to a patient's home, pick them up, take them to an appointment, wait for the patient, and take them home. So if you work with a cancer center, talk to the cancer center, talk to their Commission on Cancer organization and group. Most cancer centers are COC certified, which is Commission on Cancer, and COC committees are directly tied to American Cancer Center or American Cancer Society representatives. So if you have a COC committee, they have an ACS representative on the committee that you can connect with and see how ACS can support your patients with transportation, as well as lodging if they live a distance away and they're coming in for appointments, then they can help fund lodging for you too. So how does this translate to helping cancer rehab efforts? It translates into if you are coordinating your rehab appointments or your PT appointments, OT speech appointments and collaborating with the cancer treatments and trying to do things all in one day, that's tough sometimes. Sometimes those cancer appointments are unknowingly long appointments, but as best you can do to try to coordinate visits is helpful. I know for myself as a cancer rehab physician, if a patient is coming back to see a provider on a day I don't have clinic, I just go and see them in that provider's clinic, and that reduces another time that that patient has to find transportation to see me. And I've worked enough there to be friends with some of the providers that they don't care if I pop in during their time slot to see the patient. So whatever way we can do to help our patients get to rehab, whether it's seeing a cancer PM&R doc or seeing PT, OT speech is helpful. Online days, I know I'm not an online guru, I definitely am not, but there's so many more online resources these days as well to print out exercises for your patient, give them webpages, whatever can help them. And social support availability, it's super sad when you see a cancer patient, I've got about five minutes so I'm going to wrap it up, I promise. It's really sad when we see cancer patients not have many family members or any family members supporting them through this or any close friends to help them get to and from appointments. Utilize the social workers at your cancer institution. They are wonderful and they have ongoing updates on what community resources can help your patients. If you can offload the cost of anything, whether it's transportation, whether it's lodging, whether it's medications that they're having to pay for their cancer care, if you can offload any, some dollars spent, maybe that's dollars spent that they feel like can go towards a rehab appointment finally. It loosens their purse strings a little bit. So utilize your social workers. I'm lucky to have social workers that are disease specific. So if I'm seeing a breast cancer patient, I go right to the breast cancer social worker and communicate with her. So they are wonderful to work with. Like I said, whether it's local or national resources you have, American Cancer Society, cancercare.org has a lot of great resources you can go to. And the social workers can help connect you to reputable sources. Sometimes it's hard to know what's reputable or not. So utilize their expertise. Insurance coverage. And I am no expert on how to officially like get your way with insurance when you want some form of treatment or some form of rehab for patients. But being savvy and the outpatient is important. They only get so many visits per calendar year. So if in January, you know, you utilize all your visits within a couple months, you're kind of stuck sometimes later in the year. So trying to correlate with their cancer treatment and figuring out when is the smart time to utilize outpatient rehab. Home health obviously is helpful if they can get into the patient's home when the patient can't mobilize well. But there are so many insurance companies that aren't even covering home health these days. It's bizarre. Or home health agencies that won't partner with certain insurance companies. From an inpatient standpoint, I do peer-to-peers every week, if not multiple times a week, trying to get my patients into acute rehab. Fight for them. Peer-to-peer is sometimes you can be like, oh, do I have time to do a peer-to-peer? But it's amazing how many times I get on the phone and the insurance company says, we just don't have enough records. We don't really know where the patient is right now. We don't really know what's going on. You know the history and you can quickly convince them, oh, yeah, they do need acute rehab. They do need a PM&R physician. Oh, they have foot drop? I didn't know that. I didn't see it anywhere in the records. So take the time to advocate because it pays off for those patients. There are times that I fail and I'm frustrated. I failed this week and I said everything I possibly could think of to advocate for the patient. I'm starting to document what insurance companies are denying my patients. And maybe we all can do that as a unit. And as a team, maybe that number of denials would be powerful. I don't know. I'm just throwing that out there. Free online resources. I learned this week about a Maple Tree Alliance, which is a free online resource with videos of exercise that patients can do in their home. So anything free we can figure out for patients is super helpful. If a patient has Medicare, think about silver sneakers. I didn't even honestly know all that silver sneakers can do, but they have online free workouts. Per them, they have 15,000 fitness locations, which apparently is more than Starbucks, the number of Starbucks in our country. So go figure. So utilize them. And fitness apps, whatever is easy for these patients to do that is at no additional cost. And again, going back to figuring out what's within your community to advocate for your patients. I am lucky to have some Livestrong through the YMCA, which is a free 12-week program that you have an exercise professional helping coach your patients on how to increase exercise because they are afraid. They don't know what's safe. And just sending them with a paper handout sometimes, they won't follow those guidelines. I'm lucky enough to also have one of the greatest Gilda's Club in the nation, apparently, Gilda's Club Kentuckiana. They now, because of pandemic, have a lot of virtual classes. They'll have like easy chair yoga. Patients can remote in from their home and start doing some exercise. And I'm lucky enough to have Retain Kentucky, which helps support patients getting back to work because 30 to 60% of just breast cancer patients remain on sick leave from work about one year after treatment. So how can we support them get back to gaining employment, which they so desperately want to do but struggle to do a lot of times because of the side effects and just the toxicity of treatment. So utilize your community. Talk to your social workers. They're wonderful resources. Talk to your cancer center. Talk to your American Cancer Society representative and find ways to help your patients get the rehab care you need and be as creative as you can be. So I hope you all have enjoyed it. We've got zero minutes, sorry. I talked beyond, apparently. I didn't see the flashing light. But I hope you've learned something about overcoming barriers. We are happy to answer questions. We're not in any rush, I don't think. So feel free to ask questions. I also have a shameless plug. MD Anderson also has... Can you turn it on? Hello. I also have a shameless plug. MD Anderson does have fellowship spots open for next year. So if anybody is interested in redoing their cancer fellowships or if you know anybody else that's interested, please send them our way. We would love to have them. And I'm looking for a cancer rehab second doc. So there are jobs out there. There are jobs out there after they finish fellowships as well. Keaton, I'll take this mic to people asking questions. Can you turn it? You mentioned that there were something like 400 referrals that were canceled. How were those canceled? Were they like de-clicked by the provider? Or what exactly happened that so many were retracted or canceled or however? So I haven't been on the receiving end of that. But it's in Epic, which is the EMR that we use. So I'm sure you've gotten alerts before that you just click until it goes away. So my hunch is that's the case. Great talk, guys. And Dr. Hwan, also regarding the referral generator number two that you mentioned, one, is that alert going to the oncologist also in Epic? Yeah. Yeah. And so how many responses do you have a ballpark of who's actually responding to those? So can we go back in time? Yeah, sorry. No, no, there's a number in the... The reason why I ask is because we started a similar program at my institution. And we've really struggled with getting oncologists to actually respond to alerts. So I'm just curious if they're actually answering your question of whether these patients are safe to exercise. So I think it was further back. Oh, the preliminary data? Maybe. It was the algorithm. No, so it was further back. Oh, so this is the data from after we implemented the changes to the myonas chart. Gotcha, okay. And then this data is... So it was right... Actually, no, no. Not this? I think it was like three slides forward. So keep going forward, forward, forward. So right down, forward. So here where it says alert sent to care team via U-chart with question number three. Yeah. Yeah, so I'm just wondering, you know, do you get a lot of buy-in from oncologists? Are they actually responding to these? I've started to see more referrals generated by this process. It's not the bulk of them. And then another confounder is that we're really backlogged for a new patient to get an appointment. Sometimes it's very challenging. It can be three or four months. But over the past six months, I've been seeing more referrals that just say, like, you know, the nurse practitioner might be involved and they just put, you know, they don't know why they're being referred, but they're like, okay, this is because of my wellness check. Gotcha, okay. Thank you. Well, thank you, guys. We'll be up here to chat, too, if needed.

barriers

challenges

rehabilitation

cancer patients

prevalence

rehab services

activities of daily living

care coordination

clinical workflow

patient outcomes