All right, I got 8.02 on my clock, so respect for overtime, everyone's time, let's go and get started. So I'm Nathan Katz, part of the AAP Medical Student Council, welcome to our journal club. Today's topic, we have cancer rehabilitation, a new and exciting field in the rehabilitation realm of things. And we got three great presenters and a great clinician expert. Let me introduce Dr. Terrence Pugh here. I just have my notes on the side here, so I make sure I get everyone's titles right. So Dr. Terrence Pugh is an Assistant Professor and Director of Oncology Rehabilitation for Carolinas Rehabilitation. He's also the Vice Chief of Cancer Rehab in the Department of Supportive Oncology at the Levine Cancer Institute. So we're lucky to have Dr. Pugh. Couple announcements before I give Chris the reins here. So we have a couple openings coming up in the next couple journal clubs. We have Pediatrics, Traumatic Brain Injury, and Spinal Cord in the next couple months. We got some spots available, posting all these announcements here in the chat. So feel free to sign on for y'all who haven't tried out the journal club yet or want to present. Take a look at signing up and consider presenting the next couple months. Also Physiatry 2022 is in person and we're going to get to see everybody in person down in New Orleans. So consider signing up. There's a lot of great deals and a lot of great events coming from the AAP for medical students, residents, and everyone alike. So excited for those events coming up. So Chris, you're right to rock. So we got Christopher Radlicks, fourth year osteopathic medical student of the Ohio University Heritage College of Osteopathic Medicine, ready to talk to us today about early palliative care for patients with metastatic non-small cell lung cancer. Whenever you're ready, Chris, you can take it away. Can everyone hear me? Yep. Yep. Awesome. Thank you. Well, thanks everyone for joining. I figured things are going to be a little bit light because of the holidays and whatnot. So thanks to all of y'all for joining, being true troopers out there. But yeah, so my talk, as Nate mentioned, is early palliative care for patients with metastatic non-small cell lung cancer. So are palliative care and rehab unrelated? It might be a natural question. People associate palliative care with end of life care typically, and rehab maybe is more associated with the upward trajectory, rehabilitating, so things often improving. So as far as palliative care, palliative care, a lot of the time you're going to be talking, you're going to have an emphasis of quality of life and function. It's going to be an emphasis on goals of care, discussion, psychosocial support, care coordination, pain, mood, bowel and bladder management, family discussions, prognostication, and anticipatory guidance. And then you're going to be treating the effects of disease and side effects of treatments. So I guess first question is, how many of these do you think would show up in the physiatry side of things as well? Oh, too easy. Yeah. So yeah, maybe a little bit of a leading question there, but there's definitely an argument to be made that all of these things show up in physiatry, right? Especially family discussions, prognostication, anticipatory guidance. I think back to some time I spent on spinal cord injury units. People are asking the question, am I ever going to walk again? You know, how am I supposed to deal with this spinal shock? Or maybe they wouldn't ask that explicitly, but at least explaining spinal shock and the progression there. So definitely at least one example of relevance, but more in common than not, I would certainly argue. So the National Cancer Institute, one definition of palliative care, it's care given to improve the quality of life of patients who have serious or life-threatening disease. And the goal of palliative care is to prevent or treat as early as possible the symptoms of disease, side effects caused by treatment of disease, and psychological, social, and spiritual problems related to a disease or its treatment. And this is from the Carolinas Healthcare System, a little shout out to Dr. Pugh. This is just from one of the brochures for oncological rehab or oncology rehab. So many patients diagnosed with cancer face the challenge of cancer-related fatigue, physical cognitive impairments, and possible ongoing decline in normal bodily functions. Whether the need is to regain motor skills and strength, improve cognition, provide family education to allow a safe discharge into the home. Obviously, they're going to be helping with that. So maybe it kind of speaks for itself as far as maybe some of the similarities rather than going one by one through them. So palliative care, same heading. So there's a rising burden of chronic disease and disability. Physicians across all specialties are tasked with providing primary non-specialist palliative care in both inpatient and outpatient settings. PM&R often provides this primary palliative care by addressing the physical, psychosocial, functional needs, coordinating patient-centered care that aligns with patient's goals, and incorporating the needs of both patient and caregiver into the care planning process. So patients receiving palliative care frequently share common symptoms, including fatigue, decreased functional independence, mood disorders, pain, and breathlessness. And many rehabilitation interventions can help improve these symptoms. So like PM&R, palliative care embraces an interdisciplinary care model, attends the needs of both patient and caregiver, and focuses on quality of life for patients whom there are frequently no definitive cures for the primary disabling disease or injury. And this is a little schematic showing, it was in an early palliative care article, different article, but shows the care continuum and maybe the more appropriate intervention for palliative care. So being at the time of diagnosis, you're incorporating palliative care. And along with that, having cancer rehab involved that early on, especially with the hot topic of prehab, which we're going to hear about later, earlier on, especially before active disease, directed treatment is initiated. You want to be having physiatry on board, and then maybe a little earlier or later on having palliative care as well. So certainly a bit of a sliding scale is kind of how this is depicted. So the significance of the paper I'm going to be talking about, it's the number one cited paper in palliative care literature. Plenty of citations for whatever that's worth. And then things like Atul Gawande kind of popularized the conversation, at least in sort of the public, as far as palliative care, end-of-life care, the importance of physicians getting training and having goals of care discussions. And he definitely cited to this paper, it's at some point in the book. So talking about the value of having maybe earlier palliative care interventions, their palliative care earlier on. So the introduction to the paper, common discussion point is that percent of lifetime health care dollars are spent at the end of life. If anyone wants to wager a guess, there's definitely different numbers as far as maybe in the last year of life, what percent of total health care dollars are spent, Medicare dollars specifically, as a percent. Yeah, that's pretty good. Run out with the 33, I like that. Yeah, so I mean, definitely variable. That's more of the upper end. But around 20% is kind of maybe the middle of the road number that I've seen in the literature, but definitely up for debate. There's definitely articles out there entitled, we're definitely overestimating how much people are actually spending at the end of life. But yeah, about a fifth or a quarter seems reasonable. So oncology care is central to this because you're going to be using a lot of expensive newer drugs a lot of the time. So are you supposed to be, especially in the cancer population, giving these drugs, doing everything you can curatively until their last dying day? Or should palliative care be a little more involved as maybe the relevance? And then palliative care at this time, this is a paper from 2010, it was often delivered later in the course of disease and then later referral. So it's kind of hard to actually make sense of maybe the value or role that palliative is playing in this patient population. And this population was metastatic non-small cell lung cancer. And it's the leading cause of death from cancer worldwide. There's a high burden of symptoms, poor quality of life associated with this patient population and prognosis estimated to be less than one year. So the goals and hypothesis of the study, goal to examine the effect of early palliative care integrated with standard oncological care in patients with metastatic non-small cell lung carcinoma. And they looked at things like patient reported outcomes, use of healthcare services, and quality of end of life care among these patients. And the hypothesis that was generated was patients who received early palliative care in the ambulatory care setting as compared to patients who received standard oncological care would have a better quality of life, lower rates of depressant symptoms and less aggressive end of life care. So some of the inclusion criteria. So pathologically confirmed non-small cell lung carcinoma within the previous eight weeks. And then there's a performance scale that's used as far as kind of a general sense of function. And in this, they restricted the population to individuals that have a zero to two. So these patients are rather functional, right? They're asymptomatic, fully active. They're symptomatic, restricted activity, but fully ambulatory still. And then they're capable still of all self-care and then no work activities though, but symptomatic in bed less than 50% of the time. So the idea is that they are in fact catching people earlier on, and that was incorporated in the inclusion criteria. And the patients also had to respond, be able to respond in English and they were excluded if they're receiving palliative care previously. I realized I skipped over a slide, but this is a little jumbled of a slide, but just showing the study design. So as I mentioned, the newly diagnosed patients, they were at the MGH thoracic oncology clinic was non-blinded as a randomized one-to-one ratio. And then individuals upon randomization would do baseline questionnaires, which we'll talk about what was included and they were randomized into the standard of care or the early palliative plus standard of care. And that early palliative standard of care arm, they'd meet with the palliative team within three weeks, which included a physician and advanced practitioner. And then they'd be followed up monthly in the outpatient setting. And then they also completed a 12 week questionnaire. And this recruitment was done from 2007 to 2009. And then data analysis was done sort of through, or data was still being included and analyzed through December of 2009. So patient reported measures, maybe just touch on a few of these. So functional assessment of cancer therapy, lung scale, it's called, they're shown to be FACT-L. It looks at physical, functional, emotional, and social wellbeing and quality of life over the past week. This is an example of some of the questions that may be asked. So it's a Likert scale. And one of the examples I may work and not at all, a little bit, et cetera, et cetera. Another functional outcome that they looked at was the lung cancer subscale. It looks at seven symptoms specific to lung cancer. One of them being, I've been short of breath. And then again, answering in a Likert scale. Then there's the trial outcomes index, which includes this LCS, as previously mentioned, and some of the subsets of the FACT-L. So the physical wellbeing, which I showed initially, or the functional wellbeing, either or, but the, okay, the physical wellbeing is here as well. And then I showed the functional before. So all of those in combination create this sort of index score. And then you'd also be looking at, or they were also looking at mood. So anxiety, depression, PHQ-9, and this hospital anxiety and depression scale. Based on characteristics, as you can see, P values, none of them are significant. It shows that it's been well-balanced relatively. There's mention of, you know, EGF positive, EGFR positive patients, as far as the ones who went under genetic testing, which would indicate, you know, a more severe lung carcinoma. So it was nice that those were equally balanced as well. So it wasn't a more severe population in that sense. And then maybe to point out, because this comes up later, the racial balance, it's there, but not very diverse as far as, you know, the patient population. And, I mean, maybe I'll just highlight the known prognostic factors were all equal across groups as well. So that's going to be age, sex, et cetera. So some of the results, I skipped over some of the analysis because I'm probably running short on time, but we could revisit that if one desires. So the average number of visits in the palliative care group was four, and then 10 patients in that standard of care group actually were referred to palliative care at some point. Seven had one visit, three had two visits. And they actually, in a study, they kept these individuals within their respective groups as an intent to treat sort of study would. So it didn't cross over these patients just because they sought out palliative care. So some of the quality of life and mood outcomes that we talked about, so that FACT-L, the LCS, and the TOI, you can see they're all higher. The change increased throughout the study and relative to one another as well, but the LCS was not significant. All the rest were. And then the 12-week outcome. So this is just at the 12-week comparing the standard of care to early palliative care. And you can see the anxiety subset is not significant, but depression was significantly lower in the earlier palliative care group. So talking about end-of-life care. So 70% of the patients, 105 participants, did die during the course of follow-up. And so the documentation of resuscitation preferences is going to be higher in the early palliative care group, maybe no surprise to some extent. And it was significant. And then aggressive end-of-life care, you did see a higher rate of aggressive end-of-life care in that standard of care group. And then time on hospice care, you saw a longer time on hospice and early palliative care, though not significant. There's pretty wide ranges between the groups too. And then location of death, no sort of statistical tests were done here. This was just in the supplemental, but you could see that most people that were in the early palliative care group were able to die at home rather than, this is inpatient hospice, I believe, were able to die at home. So one would think that these would be in accordance with one's wishes. You're not in the hospital, you're not in the nursing home, you're not in acute rehab. So definitely there's certain benefit there, obviously. And then survival, this is the big headline when I think the study would have come out, that in fact, the early palliative care actually lived longer than the patients that just underwent the standard of care. So kind of dispelling all those myths as far as people hear palliative care and it means people are going to be dying. And obviously significant here as well. So they lived 11.6 versus 8.9 months between the two groups. Discussion, a little bit wordy here, but improvements in mood and quality of life, maybe the reason for the observed survival benefit is what the authors noted. And that's what's been seen in the literature or posited in the literature prior to this study. Closer follow-up means likely better symptom management, which maybe is pretty obvious too, right? You'd think that if you're being seen once a month by palliative or at least the intent is something like that, you'd have more eyes sort of seeing how symptoms are being managed as far as undergoing chemotherapy and whatnot. So early referral to hospice results in better management of symptoms, stabilization of conditions, prolonged survival, more early palliative care group had resuscitation preferences documented, which we mentioned. And it's, yeah, just leave it at that. So early introduction of palliative care also led to less aggressive end-of-life care, including reduced chemotherapy and longer hospice care. The reduced chemotherapy is also in the supplemental, those numbers. Clinically meaningful and feasible. This is a clinically meaningful and feasible care model that has an effect on survival and quality of life, similar to the effects of the first-line chemotherapy in such patients. I know there's some studies at the time of what's cisplatin-based therapy and showing the quality of life improvement. And it seems to be comparable in some of the metrics, standardized quality of life metrics. So given the trends towards aggressive and cost care near the end of life among patients with cancer, timely introduction of palliative care may serve to mitigate unnecessary and burdensome personal and societal costs. So just in conclusion, the early palliative care versus the standard oncological care, self-prolonged survival by approximately two months, clinically meaningful improvement in quality of life and mood, greater documentation of those resuscitation preferences in the EMR, and less aggressive care at the end of life. Some of the limitations, one site only, highly specialized being at MGH, these thoracic oncologists, palliative care that are specialty trained. And it's only one type of cancer, albeit, you know, a very prevalent or highly high mortality associated with that cancer. As I mentioned, lack racial diversity and ethnicity. It's an RCT, but no one was blinded. So maybe, as we mentioned, the idea of just having more frequent visits might be in part, you know, the benefits of having a control group where they had the similar amount of attention, but maybe from a different group or not even the, maybe not even a clinical group, just some kind of, you know, regularity or similarity in the amount of attention showed to the patients could be included in the future. And then, as I mentioned, also those, there were individuals that did receive palliative care, so it could, in the control group, so that could dilute the findings. And then intent to treat analysis was used, and there were some missing data. So it may be, in fact, underestimating the effect of palliative in that case. So that is it. Thank you. Sorry, I was a little over on time. Thank you, Chris. All right. Can you go ahead and stop sharing for us, and then I'll hand it over to Dr. Pugh for his first thoughts. Yeah, so great job, Chris. I think, you know, one of the things I noticed with the articles that you all chose, you guys touched on the key of cancer rehabilitation, right? So have you all heard of the DEETS model of cancer rehabilitation, right? So there's four tenets related to that. So it's preventative, right? So preventing negative outcomes related to cancer. Restorative, right? So you've had your diagnosis, your treatment, help restore that prior level of function. Supportive, supporting people while they're going through treatment. And palliative, right? So when we need to kind of shift gears and shift focus, right? So this article and all the articles today kind of touch on all these things. So with, you know, the outcomes are great, right? Early palliative care, you see the positive outcomes in this lung cancer population. The question that you have to ask in a practical aspect is the stigmas associated with palliative care and hospice care, right? So what you're going to find in clinical practice is that sometimes people do have a stigma associated with that, you know, for whatever reason, right? They've known a friend of a friend that's had palliative care, and then they just put them on hospice, and they just gave them morphine until they died, right? And so that's kind of what rattles around in people's head. Sometimes they say, oh, are you giving up on me, right? Are you saying that you don't think I can survive this? And so I think the challenge that you have to have is as a clinician, as a physiatrist, is managing expectations without squelching hope, right? So you really want to make sure that you are talking to people about their wishes, talking to them about, you know, their long-term plan, and just supporting them in whatever decision they make. So from an inpatient rehab standpoint, I rarely consult palliative care on the inpatient side, because usually the symptoms, I just manage on my own. So whether it's nausea, bowel, bladder, pain, I kind of take care of all those things in an inpatient setting and give people that opportunity to try to fight, right? And so I think, though, that when I'm looking in the mirror, I'd say, you know, am I pushing too hard? Because you're naturally going to develop a skill set that's going to allow you to fix and help. But the question that you always have to ask is, is that am I pushing too hard? So when you saw that difference in, you know, survivability was longer in the early palliative care group, that's just a general reminder that some of the things that we do do cause some issues, right? If you're given a cytotoxic chemotherapy that's causing people to have uncontrolled nausea and vomiting, they're going to get dehydrated, and that's going to expedite things, right? So you want to just make sure that you're mindful of that when you're going through your treatment, and when you're going through your training, you know, managing that expectation, making sure you're addressing the needs of the patient, getting comfortable talking to them about their end-of-life goals, talking to people about code status. What I found is, is that I, when I was early in my career, the diagnosis scared me, right? So when you saw somebody that had a stage four metastatic lung cancer, you had a glioblastoma, right? Where no matter what you do, they have 12 to 15 months to live. You know, you'd be like, oh man, I got to get people out of here. Well, you know, as you get a little bit more mature and you're in the oncology rehab space for a while, you kind of get more comfortable with it, and you get more comfortable knowing when to push and when not to push. And so just want to encourage you guys, myself as a reminder included, talk to people about end-of-life things, get comfortable in that space. As rehabilitation physicians, we are fixers, right? So we're, you know, the bad thing happens, we're going to build from there. Oncology is a little bit different because sometimes the worst is ahead as far as a functional disease burden, symptom burden, but you just want to make sure that you're getting more comfortable in that space. And then I'll open it up to anybody for any specific questions regarding this article. Thanks, Dr. Peer. Welcome. Not seeing any so far in the chat. I guess I'll pose one. So I know this was an article from 2010. Have they kind of tried to replicate this study? And like you mentioned, Chris, like less cancers with less poor prognoses, rather. Yeah, that's a good question. I'm actually not too familiar with some of the recent literature, so maybe I'll have to punt on that, unfortunately. Yeah. So you'll find, you look around, the big three cancers that you're going to see the studies on are lung, breast, and prostate, because there's so many people that have them, right? So you look at the outcomes in breast cancer patients, look at the outcome of the prostate cancer patients, you're going to see these early palliative interventions are sometimes, you know, well received. The tricky part about breast cancer is that we were so good at early diagnosis and treatment. You know, the people with breast cancers kind of have a higher degree of survivability, you know, order of years, not months, right? And then prostate cancer, even if it's metastatic, people can live five, 10 years, you know, a lot of times you'll hear of an older gentleman with prostate cancer, they won't even treat if they're, you know, a certain age, because they're more likely to die of a stroke, heart attack, whatever, as opposed to actually going through prostate. But yeah, there are different studies out there about palliative care. So big takeaway, palliative care is good. Awesome, thank you. And then you mentioned breast cancer. So I want to kind of take that as our transition and our next topic here. So we have Nicole Hatcher, our osteopathic medical student, fourth year out of the Philadelphia College of Osteopathic Medicine, going to talk about the case for prehabilitation prior to breast cancer treatment. So whenever you're ready, take it away. Okay, thank you. So thanks for reading my title for me. But yeah, that's the article I'm going to present on today. I'm Nicole, everyone. So I'm going to start off by doing a little interactive game. And it's like really low stakes, low risk. There are multiple choice questions, which might be triggering to some of us coming off of third and second year and everything. But if you would like to log on to this Kahoot, we'll just do some little intro questions. Can everyone see the screen also? Yep. But is there a link we can use? Or how do you want us to access? If you use your phone, then like go on this QR code, or you can go to the Kahoot.it and then type in the game pin shown here 379-3569. Can you put the pin in the chat, Nicole, just because we're not seeing the pin on the site. Oh, okay. Yeah. I don't know if that would work. Did that one work? Oh, yay. And I think we got a few folks in, but I don't think we're seeing our nicknames on the screen or anything yet. Oh, you aren't? Is it visible now? Not yet. Okay. Nicole, I think, oh, there we go. There we go. Is it better? Okay. Sorry, it was like sharing a different one. Okay, if everyone's basically in, I'm gonna go ahead, since we're short on time and everything, definitely answer as we go through it, though, by yourself or whatever. So we'll go ahead and get started. What is the most common cancer in North American women? A lot of these will be pretty easy. Yay, great job, everyone. It's breast cancer. So these are just some fun warmups to do. And then which type of therapy is provided after oncologic surgery? So, that's going to be our adjuvant. The leaderboard is changing. Next up, true or false, benefits of breast radiation treatment are often offset by increased cardiovascular-related mortality. If you use sketchy, you might remember that one sketch of the sea creatures and the ocean with the doxyrubicin. So, that is true. Ooh, Liz is crushing it. Look at the leaderboard. Everyone's getting all these points. And then hormone therapy can adversely affect the MSK system via... Yep, that's going to be all of the above. And our last question is a true or false breast cancer rehab is most commonly introduced before local regional therapy. Correct so that's going to be false because that leads into my article about how the importance of prehab is important. Who won? Liz yay congrats. Okay I'll go back to my PowerPoint here. Is it on this new screen now the PowerPoint? Yep yep. Awesome thank you for participating guys that might be a little silly but just something different. So leading into the article it talked a lot about all of the different reviews and articles and research that had been done about breast cancer prehab. They start off by talking about all of the treatments and their related adverse side effects. These include our surgeries so the lumpectomies, mastectomies, breast reconstructive surgeries, and adjuvant radiation, immunotherapy, and chemo, and all of those awful drugs which we heard about during our didactic years and everything. But the side effects are definitely real and they affect real people with lives and things that are going on. So they'll experience lymphedema, loss of strength, compromised range of motion, some people experience axillary web syndrome or brachial plexopathies, pain, fatigue, decreased activities of daily living, the radiation can cause radiation fibrosis, nerve dysfunction, and skin damage, as well as chemo causing that nausea, hair loss, peripheral neuropathy, chemo brain as some people call it, early menopause, decreased cardiac function, and decreased bone mineral density. So all of these local and systemic things lead to physiological and psychological and health-related quality of life challenges. So prehabilitation is defined as this process on the continuum of care that occurs between the time of cancer diagnosis and beginning and the beginning of acute treatments. So that includes the physical and psychological assessments and they establish the baseline functional level and identify impairments and they provide targeted interventions that improve patient's health to reduce incidence and severity of future impairments according to this paper. So prior to treatment, it's been shown that if people are receiving therapies prior, they have better physical condition afterwards as well and psychologically it helps with them feeling more in control of their health and their treatment outcomes. The paper then went in to discuss further general exercises. They talk about five different aspects, which I'll go over in each slide. So the general exercises are exercises that target muscle groups with resistance training, flexibility training, aerobic training, and it's been shown in people with breast cancer that if they're active before surgery, they actually have an 85% greater chance of reporting enhanced outcomes from baseline to three weeks. So some studies are listed on the right here. They've been studying yoga preoperatively that decreases anxiety in patients and in other surgeries that have had total body prehabilitation before their organ surgeries, they've have improved post-op pain, physical function, and decreased length of stay. So then we can elucidate that to breast cancer surgeries as well because that's comparable to these people having abdomo-thoracic and MSK surgeries and those outcomes as well. Women with breast cancer are known to have lower cardiopulmonary fitness. So the peak oxygen for a 40-year-old patient's actually comparable to a 70-year-old healthy patient. So putting things into perspective, their lungs are definitely at lower efficacy and lower health. Another study showed that there's, if there's increases in maximal oxygen consumption by one metabolic equivalent, that causes the 15% reduction cardiovascular-specific morbidity and 13% decrease in all-cause mortality. And then another study showed that aerobic exercise before Doxorubicin administration actually led to a greater than 40% better left ventricular ejection fraction and 13% lower mortality in those patients compared to sedentary people as well. Sorry, we went back. And then there was also a randomized control trial on acute exercise 24 hours prior to administering Doxorubicin, and that led to a less severe decline in cardiac function too. And then exercise also improved chemo completion for women with breast cancer undergoing the adjuvant chemotherapy. So it's thought that exercise and physical activity helps with people staying on their therapies because they're able to tolerate it better. The next facet of this prehabilitation picture is going to be targeted exercise. So this is the exercises that are specific to body region, depending on the disease or the treatment. So in breast cancer, we're worried about the upper quadrant area and then developing shoulder pain dysfunctions, loss of abduction, loss of shoulder mass in the pectoral girdle. Some breast cancer irradiation actually requires patients to be in that shoulder abduction and external rotation position, which we know that that's the most vulnerable position for dislocations and other shoulder pathologies. I'm putting a lot of stress on the brachial plexus and everything there. And I can't even imagine having to go through a lot of radiation on top of putting my shoulder in that much physical stress. So this study done by Bama, they studied three different exercises. So stirring the pot. So they were leaning over and doing small circles with their shoulder to increase mobility. Wall angles to scapular squeezes while arms overhead and reaching for the pillow. So overhead reaching while lying supine. And all of those were found to improve the shoulder mobility and everything and decrease incidences of frozen shoulder and things like that. And osteopathic students might compare that to things like Spencer's technique or something. So breast reconstruction surgeries also involve using the transverse abdominis. So using that muscle and taking that out is going to cause a lot of trauma to that area. And that involves and then causes decreased isokinetic strength of the abdomen. So it's thought that physiotherapy working on posture and abdominal strength would be beneficial before these surgeries as well as after. In terms of the nutritional interventions, 20% of patients with breast cancer may be malnourished prior to adjuvant chemo and 60% are overweight or obese. And sarcopenia is definitely a consideration that we have to take into account for these patients and their protein intake because sarcopenia happens naturally with age as well. But in these patients with breast cancer and irregular hormones and other things, we need to keep an eye on their protein intake. And that also can implicate their cancer treatment toxicity and tumor progression. It's recommended for patients to receive 1.2 to 2 grams per kilogram a day of dietary protein to promote optimal muscle health in cancer patients. For the energetics and bioenergetics of these patients, we have to be mindful of their microenvironments, fostering antineoplastic environments. If they're very acidic or aerobic glycolysis or extracellular acidification is happening, these microenvironments are also something that must be considered. And then the other facet of the prehab in breast cancer patients is the psychological well-being. So there's a lot of evidence that suggests that psych screening intervention immediately following diagnosis may enhance the psychosocial adjustment. And that would be beneficial across all types of cancers as well, not just specific to breast, but helping these patients to really decompress and understand what their diagnosis means to them and how they can go forward from this. Because a lot of people hear cancer and they think doomsday, which I would, that's warranted and that's definitely scary, but implementing psychological interventions or management or techniques would be appropriate here. It's been found that stress management training preoperatively is effective as well as this study that studied relaxation techniques such as breathing, progressive muscle relaxation, meditation, guided imagery, problem solving, and coping strategies all positively impacted the immunologic function as well as patient reported mood outcomes. So that's hitting the subjective and objective areas of both of those. Smoking is very bad for people, obviously, but so smoking cessation is something that we need to implement and really need to motivate our patients to do because of all of the bad outcomes that smoking is related to, such as poor treatment adherence, postoperative complications, infections, disease recurrence, mortality, wound infection, decreased functional status and quality of life, and distress and mood disorders. Another consideration for the prehab components are going to be using multimodal approaches, whereas unimodal approaches are definitely a good start, but it's more beneficial to kind of use a catch-all, all of these five. So using that general exercise, the targeted nutrition, stress and psychosocial support, and smoking cessation all together. There have been multiple studies that showed that unimodal implementations didn't actually cause any significant changes in comparison to placebos. However, when they reexamined it, the same cohorts with multimodal approaches, they found statistically significant increase in functional capacity. So multimodal is definitely the way to go, but any type of prehab is good. Here's a table from the article going through all five of those different interventions and the different examples, and then short and long-term benefits that we kind of talked about already. And then these were the challenges that this paper also discussed. So the feasibility and efficacy of implementing these programs is definitely a challenge, as with anything involving a lot of integration between multidisciplines of patients, where it's capturing nutrition and psychosocial things and things that are kind of a struggle for even people who aren't going through cancer treatments to get a hold of. And then also for breast cancer patients specifically, there's a minimized time from diagnosis to surgery now that they've done so many studies on that. It's actually recommended one month apart. So that is a very short window. So they were actually looking at trying HIIT exercises instead to hit that desired heart rate at like a more, have more efficiency basically. So doing more intense workouts rather than graded and progressing as a slower pace. And then there's also a variable window. So prior to neoadjuvant surgery, post-op and post-chemo, these are all other considerations. The comprehensive approach is to have that multimodal rehab implemented after diagnosis, before surgery, and then do a progressive post-op therapy. So in summary, there is relevance in, clinical relevance in starting prehabilitation to promote improved outcomes in breast cancer patients, but definitely more research is necessary, such as post-operative complications. There's the completion rate of adjuvant treatment, the long-term fitness of patients, weight control, and survival statistics. And that's the end. Awesome. Thank you, Nicole. And then Dr. Pugh, what are your thoughts? Yeah, so very good. So great presentation, great article. The prehab is something that when you're going into cancer rehab, you're going to hear about all the time, but those last slides were the most poignant of it all, right? How do you implement this in a timeframe before the treatment starts, right? So what I will tell you is, and practically it's a challenge, right? So if you had to coordinate an exercise program, visit with a psychologist, nutritionist, in the time from a cancer diagnosis to the time to start treatment, that's where the challenge lies, right? So if you think about, you know, just think about your perspective. If you got told, hey, I've got a cancer diagnosis, your first thought is how do we get it treated, right? And so what you find is that, and you don't even, like as a physiatrist, I don't even see these people, right? Until they have the pyramids after, right? So what I get is, you know, we've already started on this treatment course, now here we go. So the prehab window is very, very narrow in practice. Another piece that you have to consider is that if you're sending somebody to an exercise specialist or a physical or occupational therapist, what diagnosis are you putting down for them to get reimbursable services, right? Are you going to say anticipated shoulder dysfunction, anticipated radiation fibrosis, anticipated lymphedema, etc., etc., etc.? None of those are ICD-10 codes, right? And so our entire system, as great as prehab is, if you can get in there early, our entire system is not geared toward facilitating that prehabilitation. So what you see is, is that the people, and especially in the breast cancer population, they are such a motivated group of people, right? They want to get better. They can beat this. And so you'll find people that are super active before, super healthy, holistic, psychologically in a good spot, they tend to do better long-term just because of that prior level of function. So, you know, the old adage is true, eat right and exercise, because that puts you in a better position when that time comes to be able to, you know, withstand what's ahead. And so that's the challenge with prehabilitation. So you're going to see all these studies talking about it. You all as physiatrists, are you probably not going to see a lot of people immediately after they get diagnosed with a cancer, right? They're going to want to go see their surgical oncologist, their radiation oncologist, their medical oncologist. And then if something develops along the way, then they'll come to you. But between the appointments, radiation, the surgical appointments, that recovery, there's not a great window for rehab specialists to intervene. So you know, that's the future of cancer rehab. If you guys can crack that code, then you'll be rich and famous, right? But that's kind of the practical aspect of it. And that logistically is kind of a challenge for the prehabilitation. Thank you. Yeah, great job. So any questions, concerns about any of that? I actually had a quick question, if that's okay. First of all, Nicole, that was a really great presentation. Thank you so much for doing that. Dr. Pugh, this is kind of more a question for you. Do you commonly see like oncologists talking to their patients about exercise? Like, since you're the closest person to this field, I guess that I've encountered, do you notice that like a conversation exists a lot when these patients are seeing their oncologist? So what I would say is that oncologists treat, right? So their medical, surgical, radiation. So they're like, hey, we're going to spend our time talking about A, B, C, and D, right? These are what we're going to do focused on treatment. Now, the reason physiatry has a space in that is that the old mantra, the old adage of cancer treatment is, you know, we're going to keep you alive, right? So we're going to cure that cancer. So we're going to get rid of it and we're going to move forward. So your arm's swollen. Hey, we can live with that. Hey, if your shoulder doesn't work quite as well, cognitively you're a little bit off. You know, that's not kind of the focus of a lot of the oncologists. So specifically to your question, I don't see a lot of that conversation happening. Now, we are integrating within our Cancer Institute in the Department of Supportive Oncology within our Cancer Institute. So we have an entire floor, palliative medicine, psychiatric services, rehab, that we get referred early. And so what we found is that they just kind of punt it to us, right? So does anybody know the exercise recommendations for somebody undergoing treatment? How many minutes per day? And then compare that with you and I. How much aerobic activity, moderate intensity aerobic activity are they recommending for us and people with cancer? Isn't it the same? Yeah, it's the same. 30 minutes per day, five days a week. So 150 minutes per week, right? So it's not much, right? But people, you'd be surprised if people just don't carve out time to exercise, right? And so that's just kind of a little motivation for you to talk to your patients about. Because I think that we miss a lot of opportunity for folks by not talking more about that preventative, right? And prehab is kind of that, it doesn't quite fall in that preventative because it's already happened, right? They've already got cancer, right? So we talk about prehab, but it's actually after diagnosis and that window is just tight. And so it's very, very challenging for us to kind of really intervene as rehabilitation professionals in that window. Thank you for your answer. You're welcome. Awesome. We got to do a whole separate event on prehab. It's too diverse. And I just think for us to have this kind of time slot for it, but let's take a time. I want to get our buddy Ed going here. So if he's ready, we got Edward Pigenaud III, who's our third year osteopathic med student at Kansas City University. He'll be talking about impairment driven cancer rehab and essential component of quality care and survivorship. Sorry for the delay, Ed, and take it away when you're ready. Thank you, Nathan. Also want to say thank you everyone for coming. Thank you to the Medical Student Council and the AAP for providing opportunities like this for us to share and learn from one another. I want to thank our presenters also for presenting some really great presentations and Dr. Pugh, of course, for taking the time to really invest into us, hopefully the next generation of physiatrists. So my name is Edward. As Nathan said, I'm going to be brief as we are now getting later into the evening, but tonight I want to speak with you briefly on, I'm going to share this now, impairment driven cancer rehabilitation, as Nathan said. If there's any issue with how my presentation looks, please let me know. So let's jump into it. We got a lot to go over in a small or short amount of time. So this is the paper that we're going to be discussing, would highly recommend you download. I haven't seen it on the screen yet. Not seeing it? Yeah, I'm sorry about that. Okay. Yep. Yep. Let's see. This should fix it. How are we now? Perfect, Ed. Go ahead. All right. Thank you for letting me know. All right. So let's get into it. This is the paper itself. I would highly recommend if you're interested in cancer rehabilitation, downloading this article and reading it. It's a little bit lengthy, so there's no way that we're really going to be able to get into the deep details of this study. But just wanted to share one thing about it. This is taken from the abstract. So scientific literature has shown that rehabilitation improves pain function and quality of life in cancer survivors. In fact, rehabilitation efforts can ameliorate physical, including cognitive impairments at every stage along the course of treatment. This includes prehabilitation, which we just spoke about before cancer treatment, commences, and multimodal interdisciplinary rehabilitation during and after acute treatment. This review, the paper that we'll be discussing, suggests an impairment-driven cancer rehabilitation model that includes screening and treating impairments all along the care continuum in order to minimize disability and maximize quality of life. So very briefly, let's talk about not necessarily the history of cancer rehab, but what we see in terms of efficacy and practice leading up to this paper that we'll be discussing right now. So in Dr. Stubblefield and Dr. Odell's text, Cancer Rehabilitation, it's really a giant volume that has a whole lot of great things to say about cancer rehab. The authors really were searching to write out a history of cancer rehab. And what they found was that there was a great deal lacking in history. They eventually came upon some different articles and books, one called New Hope for the Handicapped, which referred to cancer rehabilitation as special rehabilitation. There was then a book called Rehabilitation Medicine. The first volume came out in 1958 by Dr. Howard Rusk. You might recognize the Rusk name associated with NYU. But the first volume had a chapter in it. And by the time there was a fourth volume in 1977, that chapter tripled in size. A little show and tell, I actually have a copy of the fourth edition right here, which I really like. A World to Care For was another book that came out in 1972, kind of outlining some of the problems that needed to be addressed for patients who had cancer and the need for rehabilitation. And I actually have that copy as well. I got it on eBay and the inside is signed. I don't know if it's real or not, but if it is, that's pretty cool. Anyways, and there are a number of articles that started to be released in the 60s on Upword. For example, this Dietz article from 1969, there was 1,237 patients that were followed over three years and it was shown that 80%, in 80% of those individuals, there was a measurable benefit of a rehabilitation program for cancer patients. The O'Toole article in 1991 showed that the 70 subjects that were followed maintained improved bladder incontinence and mobility. And Marciniak article showed that there were 159 patients over two years that were followed, showed significant functional gains. Around 1969 to 80 or so, I'll just kind of abbreviate this really interesting history with MD Anderson and Memorial Sloan Kettering. There were times where they were trying to get a cancer rehabilitation program going and it kind of worked for a little bit. There was one physiatrist in the department at MD Anderson for about a decade, and then there just wasn't one. And then there was an issue and everything kind of went downhill in terms of that program being up and running. That, needless to say, eventually, as more effort was put in, those programs were developed, more research was done, and now we can proceed forward. So when we go to the paper, basically the introduction is very long and filled with some really great information, but I'm just gonna give you some highlights here. First, the introduction kind of states this overview, this is an overview and a laying out of the problem of issues related to cancer rehab. We know that there, and this was an article from a few years back, so the statistics will be newer now, but it was estimated that U.S. cancer survivors would increase from 13.6 to 18 million by 2022. You've probably heard the statistic that, I think CDC statistic that one in two men will get cancer in their lifetime, one in three women. So cancer is certainly prevalent. 3.3 million U.S. cancer survivors may have poor physical health, and 1.4 million might have poor mental health. The health-related quality of life in the article says that often more influenced by physical issues than emotional issues, which is quite significant. And impairments are often present, but undertreated. We'll talk about that in a little bit. And the cancer patients need a rehabilitation. I will kind of speed through some of this, but this article by Thorson here on the bottom, there were 1,325 survivors of the 10 most prevalent cancers. 63% reported a need for at least one rehabilitation service with physical therapy being the most frequently reported need at around 43%. However, this study also showed that 40% of these patients were not getting this need met, the rehabilitation needs met. So something very important listed here in the article, I'm going to try to get rid of this on my screen. I don't think I can, but anyway, I can read it here. They say in the paper, there's a need to better understand and clarify the field of cancer rehabilitation, including the selection of appropriate screening for impairments and subsequent disability, as well as the identification of healthcare professionals who are qualified to treat patients for their rehabilitation needs. This is kind of the crux of the matter. We have to appropriately screen, and we need to get, after we've identified impairments, bring in team members who are qualified to address these impairments. I'm going to breeze through this. So as far as screening goes, there are four main categories that are kind of referenced in the article, general performance, mobility and balance, fatigue, and distress. I'm not sure how well you can see this table one as part of the article, but here are some different measures that I'm sure all of you have seen before, FIM scores, you know, the timed up and go test, six-minute walk test, and so on. But really what this paper is alluding to is the fact that we need kind of objective measures to appropriately and effectively screen for impairments so that afterward we can, of course, take care of those. They say in the paper that it's important to focus on screening for physical impairments from mild to severe as they need to be identified and treated to improve survivors' physical and psychological outcomes. When it comes to referral, that's the second part of it. The authors say that it's important to refer cancer survivors who have problems amenable to rehabilitation interventions to the appropriate healthcare professionals who have expertise to evaluate and treat their physical impairments and maximize functional status. So if you look at this, you'll see there's a lot of different ways that we can identify impairments and then treat those or address those, whether it's with a prosthetic, an orthotic, therapeutic exercise, EMG, swallow evaluation, and the many different disciplines that correlate to these issues. Important to identify those. Here are some other, we're not gonna go through all of these, but just some other common interdisciplinary rehabilitation team strategies and ways in which we can address the functional issues that you might see in cancer patients who need rehabilitation. There are many. There's an even bigger table in the article which I invite you to explore whenever you have time. So in the introduction, they essentially say that if we are able to effectively screen and refer, then we're gonna find, and we have several studies to back this up, that we'll see patients overall have significant improvement in their function, reduced disability, lower direct and indirect healthcare costs, increased physical and psychological healthcare related to quality of life, and more, of course. So the next part of the article after the introduction goes into identifying physical impairments in patients with cancer. First thing they talk about is pain. 30 to 50% of patients undergoing acute treatment will experience pain, and up to 70% with metastatic disease will have pain. The pain can be either due to malignancy itself, side effects or after effects of the treatment, or other unrelated comorbidities. And in the interest of time, I'm gonna go to the next slides a lot quicker. Another impairment that we wanna look at is fatigue. 75% of patients with cancer will have cancer-related fatigue. There's an increased risk or likelihood that they'll have fatigue if they have any type of cancer-related treatment, and it's more likely to see cancer patients with fatigue if there are also comorbidities or other conditions present, insomnia, inactivity, chronic pain, and mood disorders. Chronic cancer-related fatigue is defined as an overwhelming and sustained exhaustion and decreased capacity for physical and mental work that is not relieved by rest. Some treatments that are listed in here are getting, or are approaches, getting or promoting improved quality of sleep. This is particularly significant because rest on its own is not as effective at helping these patients, addressing pain, treating depression and mood disorders. And exercise, we all know that exercise is medicine. This is a huge point. Old in red know this for the test and in life. Even while undergoing treatment, studies will show time and again that exercise, even during cancer treatment, is going to result in improvement on several different levels. A couple other impairments. Neurologic impairments. These can be due to the malignancy itself or treatments that cause neurologic impairments. Some strategies that the authors say we must consider is the rapid decline of patients, the rate at which they decline, toxic effects of treatment, recurrence, fatigue, again, and psychological and family issues. Chemo-induced peripheral neuropathy is the most prevalent neurological complication of cancer. 50 to 60% of patients treated with taxanes, for example, will have chemo-induced peripheral neuropathy. Some interventions include balance training, orthotics, patient education. Mild cognitive impairment or chemo-brain, which we heard about earlier. For this issue, physiatry and occupational and speech therapy consultations are often helpful and neuropsychological testing to identify specific deficits can be helpful as well. Brain tumors. Rehabilitation after brain tumor resection has been shown to result in better outcomes, including gains in functional status and discharge to home. In a more recent study of 106 patients, the most common impairments related to brain tumors were pain, ataxia, seizures, paresis, cognitive dysfunction, and visual impairment. Spinal cord injuries or cancer-related spinal cord injury incidents may actually exceed that from trauma and represents the most frequent type of non-traumatic SCI. I thought that was really interesting because you think trauma would be at the top of the list, but actually cancer-related spinal cord injury might be higher than that. And there's a few different sequelae you might see as a result of spinal cord injuries there. Bony metastasis is another physical impairment we would want to recognize where there could be pain, functional limitation, a couple of different strategies, rehabilitation approaches or modalities we want to focus on are listed here. I really am going to get through this faster, but I do want to say one thing about avoiding bed rest when possible. In the article, it says it should be recognized that the rehabilitation of patients with skeletal metastasis has multiple inherent risks and strategies to exercise these patients remain largely theoretical due to lack of empiric data. However, the alternative to rehabilitation therapies is often bed rest, which carries its own set of potential complications, including muscle contractures, weakness, atrophy, osteoporosis, orthostatic hypotension, pressure sores, pulmonary infection, and an increased risk of thromboembolic disease. So we want to try to avoid bed rest when possible. Soft tissue impairments, lymphedema, high prevalence in breast cancer patients, 15 to 30%. And interesting note here, as far as treatment goes, complete decongestive therapy, if you initiate it early in some instances, it can potentially reverse the lymphedema altogether. Weightlifting was also shown by Schmitz et al. in 2009, was once traditionally believed to be contraindicated, but now subsequently has been shown to be beneficial. Radiation fibrosis can cause impairments as well, contracture, loss of muscle, and there's lots of treatments, manual release techniques, Botox, other treatments that can really make a difference and improve functionality in these patients. So prehabilitation, I won't talk about this a whole lot because we just heard a whole lot about it, and it's really great, but I will say here that the goal in essence is to limit future impairments, and here a multimodal approach is preferred with intermittent reassessments along the way. So what does this actually mean? This means that we're not just going to necessarily include exercise in prehabilitation, but we want to look at nutrition, we want to look at mental health, we want to look at sleep, we want to look at a holistic, we want to gain a comprehensive view of what is contributing to the overall constitution of the patient, bolster those individual areas to essentially get patients as strong as they can get before they undergo any treatment, and this is prehabilitation. Here's a lot of really great advantages, but we already know about those. Three quick things I want to cover before we move on. So rehabilitation during acute, we know we can have prehabilitation before cancer care, there's shown benefit to rehabilitation during acute cancer care, like delayed disease and treatment-related decline, less postoperative pain, reduced hospital stay, faster return to activities. It sounds great. After cancer care, exercise, for example, might have beneficial effects on health care-related quality of life and certain domains for cancer-specific concerns, body image, self-esteem, fatigue, and anxiety. To sum it up, research supports rehabilitation during cancer care. I want to get to the discussion, so I'm going to go through this a little bit faster. Rehabilitation in patients with chronic cancer. So much of disability associated with advanced cancer care may be avoided and stated, this is from the article, it's stated that this is an important public health issue, this paper by Shaville here. So rehabilitation can promote improved mobility, fatigue, sleep quality, and even in some cases where there's delirium prevention there. There was a study by Spill, and we talked about this earlier. Jacqueline actually had a question about this, so I wanted to make sure to share this. In 2012, there was a survey that was released to 805 folks, 395 people responded. Basically here, 8.4% of the oncologists were willing to refer for rehabilitation, and in contrast to 15.1% of physiatrists reported as 35% willing to accept a referral. Authors concluded that oncologists view prognosis as more significant barrier to rehabilitation services than do physiatrists. So there is a fundamental difference at times, of course, we can't say across the board, but in general between oncologists who may view the need for rehabilitation a little bit differently, who also define quality of life perhaps a little bit differently than physiatrists do. And one thing that I know that I've heard so many times from my mentor is what's the goal? What's the goal? What's the patient's goal? And this is important because quality of life will mean different things for different people. So the conclusions here in this paper are essentially that all cancer patients and survivors should be screened for psychological and physical impairments throughout their care continuum, not just at the beginning, not just at the end, but throughout. These impairments should be identified and treated by qualified professionals, not just anyone, but people who can effectively address the impairments. And that an interdisciplinary and a multimodal approach is preferred. So what I really would like to do, I don't have a whole lot of questions as far as stats for you to know or anatomy for you to tell me about, but I would really love to hear what everyone has to say and also what Dr. Pugh might have to contribute as far as, well, how do we actually do this? How do we move this to the next level? Is it that we need more research? Would social media play a role in increasing awareness? Do we need to see more things in the media related to rehabilitation? Is there importance of developing relational equity and trust among team members? Is that gonna be the biggest factor that actually propels us into a time where rehabilitation for cancer patients is not something that's being ignored? And so we can increase or promote optimal treatment outcomes. Kind of a loaded question, but does anyone have any thoughts as to maybe something that's not listed here or commenting on something that's listed here as to how we can move things forward and get patients with cancer who need rehabilitation, the care that they need? Yeah, so, I mean, this is where the money is, right? This is kind of the essence of what we do, right? So identification of impairments related to treatment and then doing something about those. Now, you touched on referrals, right? You touched on getting people through the door and that is frankly the biggest challenge, right? Are you in an environment where you have a lymphedema trained therapist, a pelvic floor therapist that can help with incontinence, dyspareunia, are you, you have a neuropsychologist who's comfortable dealing with brain tumors, right? And so making sure that you have a team of qualified professionals around to address specific disease, specific impairment is key, right? And so I think that that's the key, whether it's the stress screening, we're using a tool that all oncology patients utilize, right? And so as they get an iPad, they take a survey, it's called Tritium and they basically generate referrals based on their symptom screen. What we're finding is that it probably over refers to rehab, right? And so then you get 500 referrals in a month and then from the structure, you don't have enough practitioners to manage that. So being strategic in the patients that you can intervene with is part of it, right? And so those are the things that we have worked on. We, establishing relationships is key. We go sit in tumor boards, we have an inpatient consult service, we have outpatient clinics, we have all those things to kind of get the word out, but getting people where they need to go and practitioners trained and passionate about the field are key. When you go to these conferences like, excuse me, AAP and more interdisciplinary organizations at times, you will find that some practitioners have an interest in cancer rehab, wanna provide services to patients, but they have trouble just getting referrals because like you said, sometimes the diagnosis discourages at times, getting those referrals. So there's a lot of stigmas out there. Social media is one, we have a YouTube channel where patients can go and kind of see, the Department of Supportive Oncology, several things out there. So we're getting the word out as best we can, but still a lot of work to do. Great points. Does anyone else have it? Yeah, I had a comment too, because so at my institution, they have like a comprehensive center similar to what you were describing in the Carolinas where it's multidisciplinary. So basically the patient engages either during the diagnosis or throughout treatment. And there's a couple of physiatrists that are running clinics on a regular basis. What percentage of, I guess, institutions do you think have that model that kind of works where you can actually, you have the ability, basically you're working side-by-side with the treatment physicians to get to the prehab and get an early intervention to these patients. Right, so that's a good point. Right, so that's a loaded question. What I would say is there's not many. What I would say is that there's a limit in the number of physiatrists, right? So there's eight fellowship programs in the country. So there's eight cancer rehabilitation physiatrists coming out per year, eight, right? And so if you look at the order of 18 million cancer survivors, we're not quite there as in the number of patients that are gonna be, need our services and can drive it forward. So what you actually find is that the impact is gonna be made through our therapy services and our ancillary services. There's just not enough of us to do it all, right? And so we should encourage our physical and occupational therapists, our speech language pathologists, our neuropsychologists to really branch out and get more comfortable in that space. So we've established a regional oncology group, which is essentially, we have our processes and protocols and actually train different therapy centers on some of these processes because we can't be everywhere for everybody at the same time. So I would say it's very, very rare to do that. And it's probably not gonna be physiatry led just because of a sheer number standpoint. Awesome. So I wanna thank y'all for this great discussion. We're super over time. That's mostly because this field is so new, so interesting and so important. So I wanna thank everyone for their time because we've had such kind of great discussions about this. I'm gonna make it my duty to really try and get more of these in the journal club. We're at the AAP. We're gonna kind of keep trying to push cancer rehab and get it more out there for all the reasons we've all mentioned tonight. So, sorry, I gotta cut things a little short in the discussion, but wanna thank all our speakers again tonight, Ed, Chris, Nicole, and then Dr. Pugh again. But I wanna thank y'all for coming out and really great discussions tonight. Thank you all. And just email me if you have any questions or concerns. Thanks Dr. Pugh. Everyone, happy holidays. Happy new year. Be well. Bye.

prehabilitation

cancer patients

breast cancer

physical assessment

psychological assessment

exercise interventions

nutritional interventions

improved outcomes

cancer rehabilitation

physical impairments

quality of life