Vital Role of Oncology Rehabilitation

Podcast Transcript

Dale Shepard, MD, PhD: Cancer Advances, a Cleveland Clinic podcast for medical professionals, exploring the latest innovative research and clinical advances in the field of oncology. Thank you for joining us for another episode of Cancer Advances. I'm your host, Dr. Dale Shephard, a medical oncologist here at Cleveland Clinic Directing the Taussig Early Cancer Therapeutics program and Co-Directing the Cleveland Clinic Sarcoma program. Today, I'm very happy to be joined by Dr. Eileen Slavin, a physiatrist specializing in oncology rehabilitation here at Cleveland Clinic. She's here today to discuss empowering recovery through oncology rehabilitation services. So welcome, Eileen.

Eileen Slavin, DO: Thank you so much for having me, Dr. Shephard.

Dale Shepard, MD, PhD: Absolutely. So we have a wide range of people that might be listening in, so let's start with something basic. What is a physiatrist?

Eileen Slavin, DO: Absolutely. So a physiatrist is a physician who focuses on essentially restoring function. So in physiatry we don't have a body system that we cover because function is our body system. So we take care of patients who have a history of traumatic brain injury, spinal cord injury, stroke, congenital pediatric conditions, also oncology rehabilitation which we'll be talking about today, and additionally sports related injuries too.

Dale Shepard, MD, PhD: Okay, so a lot of different things that you can cover, but specifically, what are you doing here at Cleveland Clinic?

Eileen Slavin, DO: Yes. So at Cleveland Clinic, I am starting the oncology rehabilitation program. So I'm seeing patients who either have a history of cancer or have a diagnosis of a particular cancer and are going through treatments.

Dale Shepard, MD, PhD: All right. And so when we think about patients, you said people have had cancer, people can go in treatments, what kind of conditions might you encounter a patient there? They come in and they say, "This is bothering me." What kind of things are you looking at?

Eileen Slavin, DO: So it's highly specific to the diagnosis that a patient has, but essentially many of our patients have pain, so that could be neuropathic pain or musculoskeletal pain that impacts their function. So that could be a patient who has received chemotherapy and might have a foot drop perhaps from their neuropathy. That could be a patient who has a diagnosis of breast cancer, who has shoulder pain and chest wall pain because of their surgery, because of their radiation. So those are sort of the bulk of what we see. But we also see diagnoses that are very specific to the cancer diagnosis. So some patients have what's called radiation induced fibrosis. So they receive radiation for their cancer. And because radiation effects continue, throughout the patient's lifespan, they might have trouble moving their neck. They might have pain associated with that. Some of our patients are at risk of developing lymphedema. So we can target patients who might be at risk, screen them, and prevent them from developing what we consider to be a full-blown lymphedema.

And also, additionally, this is important too, when patients are first diagnosed, if they are going through a very intensive treatment course, so they're getting chemo, they're getting radiation, they're getting surgery, they're sort of getting the whole kitchen sink thrown at them for their cancer, we do pre-habilitation. So we can evaluate them and we can say, okay, these are the recommendations that we have to make sure that you're not losing muscle mass, you're not losing function, and you have the ability to tolerate whatever treatment that you might be planned for. And that's even true for patients who are being treated in a palliative sense. So if someone's getting palliative chemotherapy, they still need to be able to tolerate it.

Dale Shepard, MD, PhD: So if we think about caring for cancer patients being team approach, how does what you do sort of work in tandem with physical therapy, palliative medicine? Why would someone see you compared to the other groups?

Eileen Slavin, DO: One of the best parts about working as a physiatrist is that we utilize a team-based approach, and we can't properly care for all the patients that we see without the help of our physical therapy colleagues and our palliative medicine colleagues. So we typically evaluate the patient from a medical perspective, and our treatment plans can be quite diverse. If we include physical therapy in that plan, our PT colleagues are very helpful with actually doing the therapy sessions with patients, providing additional recommendations, helping us to improve function. And then sometimes when we have patients undergoing physical therapy, sometimes if they're not making progress as much as they should, we have a really good collaborative discussion about, hey, maybe a patient would benefit from a nerve block, or maybe a medication, or maybe a prosthesis or orthosis. And then our palliative care colleagues are especially helpful. We refer patients back and forth quite frequently. Palliative medicine is very helpful for goals of care discussion, and also for cancer related pain that can't be treated maybe more conservatively.

So if someone has perhaps a metastatic bone lesion that's very painful from a particular cancer, they're very helpful with some opioid therapy and additional medications that can be helpful for our patients that aren't necessarily sort of focal and specific like for shoulder pain or knee pain or something like that.

Dale Shepard, MD, PhD: You mentioned prehabilitation previously. So oftentimes I think we think more about we do something as physicians, and then we like, well, how can we help people afterward, either from residual cancer, our treatment effects, things like that? This prehab concept is not something we maybe think about as much as we should. Give us a little idea about what exactly that entails. Is this sort of taking a patient who maybe fit enough in making them more fit to minimize complications, getting patients who may or may not be tolerating or able to tolerate something and getting them to a point where they can? Tell us a little bit about what that looks like.

Eileen Slavin, DO: Prehabilitation is actually for everyone. So we have patients that you would typically define as fit in terms of if we took different functional outcome measures and looked at them, we would say, okay, this person, all things considered, is quite physically active and fit. And we also have patients who have comorbidities, have risk factors, have low performance status. If we did some of those functional outcome measures like sit to stand, balance testing, timed up and go, some of those things, they might not perform that well. And essentially, it's a multidisciplinary approach. So it would be my evaluation of the patient. It would be physical therapy helping us, occupational therapy. Typically oncology's involved. We also have dieticians because we think about muscle loss and muscle wasting, particularly with cancer associated cachexia. Some patients have sarcopenia. So it's basically a whole team putting their heads together to say, okay, what kind of physical activity recommendations and exercise oncology recommendations can we start for this patient to build them up? And then also, how are we managing pain in the process? How are we offering psychosocial support?

So our psychologist colleagues are also very helpful too in that process. And the process of pre rehabilitation looks different depending on the cancer type too.

Dale Shepard, MD, PhD: I guess when you think sort of on the medical oncology side, we know that performance status is really, really important. So whether patient's even able to get treatment, how well they tolerate treatment.

Eileen Slavin, DO: Yes.

Dale Shepard, MD, PhD: We talk about geriatric patients, and we know that that's an important part of determining their course. Why do you think there's been less emphasis in the past on rehabilitation?

Eileen Slavin, DO: I think because of the urgency of a cancer diagnosis, I think that most of us in the medical field would recognize, okay, this patient just received a potentially devastating diagnosis. We need to act fast, and we need to do all that is planned appropriately for this patient, and get them started and get them going. I believe now that because survivorship has increased so much, and will continue to increase as our therapies become more personalized, I think we've sort of had to take a look in the rear view mirror and say, "Hey, wait a second. That could have gone a little bit better." And for specific populations, particularly with solid tumor, if you're thinking about neoadjuvant chemotherapy, you're thinking about a patient who will undergo so many cycles of chemo before other planned treatments typically. So we have some time, and we can impact the outcome.

Dale Shepard, MD, PhD: And I guess just for some perspective, if we refer a patient, we're thinking about sort of a prehab program. How long do you typically need to work with a patient before they're optimized for those treatments?

Eileen Slavin, DO: Absolutely. More time, of course, would be beneficial. I would say probably at a minimum four to six weeks, understanding that with some cancer diagnoses and with staging and treatment planning, you might not have four to six weeks. I mentioned the neoadjuvant group just because we typically have a little bit more time, again, depending on the diagnosis. And of course, it looks different for different populations too. So I'm in the process of putting together some of those prehab programs here for Cleveland Clinic. But when you're thinking about, for example, liquid tumor, you also have to think about blood counts. You also have to think, okay, these patients are pretty sick and susceptible to picking up an infection, so can we see them perhaps when they're hospitalized early on before they're discharged, and before they've even received their transplant? It's specific to the patient population. But to answer your question, typically four to six weeks would be ideal.

Dale Shepard, MD, PhD: You did mention that pretty much any patient might be able to benefit. But the reality is you can't see everybody.

Eileen Slavin, DO: Absolutely.

Dale Shepard, MD, PhD: And so if we think about patient selection, who are kind of the optimal people to have you see? What kind of patient selection factors do you think about?

Eileen Slavin, DO: So patients who have certain risk factors in comorbidities. So someone who might have an elevated BMI, someone who might have chronic pain syndromes, a patient who has a diagnosis of diabetes who might have difficulty with healing. Patients who are certainly motivated and interested in doing prehab, of course, are good candidates. Patient selection can be sort of tricky, but thinking about that patient that you might worry would slip through the cracks. And maybe that patient is already having a little bit of difficulty with their diagnosis, is already asking questions like, well, will I be able to get up and walk around? Will I have this type of pain? Will I lose function? Those are also patients who would be good to refer to our service.

Dale Shepard, MD, PhD: And then I guess we think about as we treat patients with cancer, we think about surgery and radiation oncology and medical oncology.

Eileen Slavin, DO: Yes. Yes.

Dale Shepard, MD, PhD: I guess sort of as the world looks now with the resources we have available, sort of the programs in place, is there a group that clearly benefits maybe more than others, surgical patients, radiation oncology patients, medical oncology patients?

Eileen Slavin, DO: Absolutely. Everyone can benefit from prehab. Of course, there's some good data, limited, I'll, bet for liquid tumor for patients undergoing prehab, improving overall survival. Our colorectal colleagues have been especially prolific in terms of publishing for prehab, and some of the other solid tumor teams across the country and across the world have published a pretty good deal about prehab. I think that since this is an ongoing and developing process, as time moves forward, we'll have more and more data. And some of my colleagues around the country are sort of in process with creating some of these programs, collecting data, collecting information for cancer rehab related registries as well. So I think things will continue to unfold. I'm also in the process of looking at our data here too and seeing how I could impact and which populations are sort of most at risk.

Dale Shepard, MD, PhD: So you mentioned something about survival and research. And can you give us a little idea about big picture? What do we know about survival benefit?

Eileen Slavin, DO: Yes, absolutely. So survival benefit has been demonstrated for many different cancer diagnoses. There have also been studies that have looked at readmission rates and improving length of stay for patients who have undergone prehab programs. Again, that data's a little bit more robust for our solid tumor patients, but as time moves forward, and hopefully I'll be able to collect some data and sort of demonstrate that here, but our subspecialty is also waking up to this idea that, okay, we know that we're helpful on sort of an anecdotal level, and we know that our patients provide good feedback, but how are we actually demonstrating our value and proving our worth, so to speak, within oncology, and within medicine as well.

Dale Shepard, MD, PhD: Yeah. We've talked about rehab, a little bit about rehab. Is there anything particularly is exciting right now within a rehab space that you'd like to share?

Eileen Slavin, DO: Yeah, absolutely. So as medicine is becoming more and more personalized, even for oncology treatments, it will be very interesting to see how immunotherapy evolves, and to monitor some of the treatment response for our patients to immunotherapy that is sort of growing and evolving every day. Some of the conversations that I've had with my colleagues have been, how do we address some of those unique challenges of, "Hey, I have this patient who underwent treatment with this immunotherapy and this could be a potential side effect of the treatment. How are you handling that at your institution? This is what I've done." So there have been some really kind of interesting theories and ideas proposed, and I think some of that will sort of evolve, like I said, over time.

Dale Shepard, MD, PhD: So when you think about patients that you may be seen in rehab, survivorship is, of course, important. Tell me a little bit about how you might help patients that develop bone metastases.

Eileen Slavin, DO: Yes, absolutely. This is another group that requires a very aggressive interdisciplinary approach. We know that these patients are living longer, but some have pretty extensive metastatic lesions, which of course makes any kind of exercise or physical activity, or even being able to do activities of daily living quite difficult. So that is something I'm interested in doing here, actually having an interdisciplinary clinic for patients who have metastatic lesions to put the heads together of all the oncology teams, orthopedics, physical, occupational therapy, myself and our dietetic colleagues as well, just to try to sort of ease the pain burden, help improve function, help maintain as much function as possible. But it can be quite complicated. And of course, we treat the person not the disease, so we have to think about every person's unique characteristics, unique challenges, specific requests, depending on their hobbies, their activities, and what they're facing.

Dale Shepard, MD, PhD: And I guess from the information sharing part.

Eileen Slavin, DO: Yes.

Dale Shepard, MD, PhD: Any advice? So somebody listens in like, why aren't we doing that? Any advice to people might be listening, how they might approach starting a program?

Eileen Slavin, DO: I would say making sure that you have that collaborative effort, and honestly, reaching out is the best thing. So I spend a lot of time in PubMed looking at updates, latest treatments and outcomes, also within my field, having conversations with your colleagues in rehabilitation, reaching out to your oncology teams and asking for their help with patient referrals and sort of demonstrating your value of, "Hey, this is all that I can provide for you. What do you think? What's your feedback?" I found that the collaborative piece has been really easy in particular here, but most of our oncology colleagues across the country are very willing to collaborate and help us. And the more information that we have, the more data that we collect, the more collaboration, the better things will ultimately be for the patient, and that's our goal.

Dale Shepard, MD, PhD: That's great. So certainly taking care of patients with cancer involves lots of people.

Eileen Slavin, DO: Yes.

Dale Shepard, MD, PhD: You're doing some fantastic work, and look forward to working with you.

Eileen Slavin, DO:

Yes. Thank you so much.

Dale Shepard, MD, PhD: To make a direct online referral to our Taussig Cancer Institute, complete our online cancer patient referral form by visiting clevelandclinic.org/cancerpatientreferrals. You'll receive a confirmation once the appointment is scheduled.

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