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Integrating the RKin into Oncologic Care
OKA Spring Education Day
May 7, 2016
Mississauga, ON
Daniel Santa Mina, Rkin PhD
Assistant Professor, University of Toronto
Scientist, Princess Margaret Cancer Centre
Disclosures
• Staff Scientist - Princess Margaret Cancer Centre
• Assistant Professor - University of Toronto
• Funding
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Prostate Cancer Canada
Canadian Institutes for Health Research
Canadian Breast Cancer Foundation
Princess Margaret Foundation
University of Guelph-Humber
University of Toronto
Astella Pharmaceuticals
Before the RKin can be integrated
in oncology…
Exercise must be accepted in oncology
Exercise Research in Cancer
SEARCH: ("physical activity"[Title]) OR "exercise"[Title]) AND "cancer"[Title]
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2015
# of publications
300
…150 in 2016 so far
Year
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QOL
Physical function
Appetite
Immune system function
Cardio-pulmonary function
Depression & anxiety
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Sleep
Bone Health
Body Composition
Hospitalization
Treatment Completion
Fatigue
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Pain
Postoperative LOS
Social roles
Self-efficacy
Coping
Tumour cell growth
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Insulin sensitivity
Concentration
Lymphedema
Functional mobility
Sexual function
Survival
Exercise Trials @ Princess Margaret
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Prehabilitation for radical prostatectomy for Prostate Cancer
Pelvic floor exercises for radical prostatectomy for Prostate Cancer
Exercise delivery models (Group vs home) for for Prostate Cancer
iMove: exercise + health Coaching for Breast Cancer
Exercise pre, during, post stem cell transplant
Group-mediated CBT to enhance PA for Gynecological Cancers
Sport training with varsity athletes for Testes Cancer
Evaluating the Wellspring Cancer Exercise Program
+ more…
Top 10 Research Priorities in Exercise & Cancer
1.
2.
3.
4.
5.
6.
7.
8.
9.
Does PA reduce cancer recurrence and/or improve survival?
Does PA influence cancer treatment decisions, completion rates, and/or response?
What is the optimal PA prescription for cancer survivors?
What is the role of sedentary behaviour in cancer survivorship?
What are the most effective PA behaviour change interventions for cancer
survivors?
Which cancer variables modify the PA response?
What are the safety issues concerning PA in cancer survivors
Which specific cancer symptoms can be managed by PA?
Is there a role for PA in advanced cancer?
10. How to translate PA research into clinical/community practice?
(Courneya et al, Jan 2015, Res Quart Ex Sport)
Exercise IS Recommended after a Cancer
Diagnosis…
Essential Components of Survivorship Care
• Prevention of recurrence and new cancers
and other late effects
• Surveillance for cancer spread, recurrence,
or second cancers; assessment of physical
and psychosocial late effects
• Intervention for consequences of cancer
and its treatment
• Coordination between specialists and
primary care providers to ensure that all of
the survivor’s health needs are met
Hewitt M, Greenfield S, Stovall E, eds. From Cancer Patient to Cancer Survivor: Lost in Transition. Washington, DC: National Academies Press;
2006.
Princess Margaret Cancer Centre
• Toronto, Canada
• In 2015,
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17,460 new patients
92,456 radiation visits
34,851 outpatient chemo visits
6,201 surgeries
368 stem cell transplants
Funding Drives Innovation in Care
Need:
1. Education
2. Clinical Care
3. Support
4. Research
Want:
Comprehensive
Survivorship
Program!
ELLICSR: The Collaborative Centre for Health
Wellness and Cancer Survivorship
Founded in 2010
Mission:
•
To maximize the QOL, health & wellness of all who
are impacted by cancer
Goals:
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1
Harness the power of survivor communities
Enable survivors1 to become empowered experts in
the management of their health & wellbeing
Accelerate research & innovation in survivorship
programs & services
Transform care by integrating evidence-based selfmanagement support
A cancer survivor is defined to be anyone who is touched by cancer, including patients, families, friends, and caregivers
Comprehensive Survivorship Care
Survivorship/Rehabilitation Clinics
Physiatry
Consult
Fatigue
Function and
Mobility
Lymphedema
Neurocognitive
Return to Work
Consult
Sexuality
Consult
Patient
Education
To Integration…
First exercise clinical trial
@ Princess Margaret
first evidence-based
guidelines in
exercise and PCa
2010
2009
2008
2007
• Initial Research into Fitness &
Exercise and PCa
• Delivered Exercise Seminars
at Prostate Centre
2016
Referral
CEP
MD/RN/Psych
Screen / Assess
12’
CEP
(MD if necessary)
Exercise Prescription & F/U
CEP
8’
integrate exercise
into clinical care for
ALL cancer
survivors
To Integration…
First exercise clinical trial
@ Princess Margaret
first evidence-based
guidelines in
exercise and PCa
2010
2009
2008
2007
• Initial Research into Fitness &
Exercise and PCa
• Delivered Exercise Seminars
at Prostate Centre
2016
???
Foundation & Research Financial Support
The
Weinbaum
Family
Wellness & Exercise for Cancer Survivors (WE-Can)
Initiated in 2014
Our Mandate:
•
•
Support the well-being of cancer
survivors with evidence-based exercise
programming and related-services
Conduct novel research into the effects,
accessibility, and support of exercise
programs for cancer survivors.
Steps to Implementation
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Model
Team
Roles and Scope
Facilitators & Barriers
Programmatic Structure
Steering Committee
Medical Director (Physiatry), Administration, Clinical Practice Lead,
Patient Advocacy, Patient Education, E-health & Innovation, Kinesiology
Clinical
Sub-Committee
Research
Sub-Committee
Physiatry, PT/OT,
Exercise Physiology / Kinesiology
Oncology, Behaviour Change,
Knowledge Translation, Kinesiology
Clinical-Research Program Coordinators
Trainees,
Students
Patient
Education
Administrative
Support
Digital
Communication
MD, PT, OT
Comprehensive assessment
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Clinical history
Functional capacity
Add’l CV, MSK, Neuro eval
Exercise/PA needs
Triage
Internal MD
Referral
Interdisciplinary
Intake Assessment
RKin Fitness
Assessment
Home-Based
Program
RKin
Fitness assessment
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CV Fitness
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VO2 or 6MWT
MSK fitness
Body composition
PA History
Goal Setting
Home-Based Program
Participant’s
Exercises
Provided with stability ball, resistance bands, and an exercise mat
Internal MD Referral
Interdisciplinary
Intake Assessment
RKin Fitness
Assessment
Home-Based
Program
Wkly Group-Based
Booster Sessions
Outcome
Data all
time points
On-Line Resources
Follow-up
Wk 6, 12, 24, 48
Aerobic +
Resistance
Team Composition, Roles & Scope
• Where does WE-Can fit within a multidisciplinary
program?
• How does WE-Can adapt within a medical /
rehabilitative model?
• Who are the appropriate HCPs to work with cancer
patients at various stages of health (disease) and
fitness?
Remember Starting a New Job?
• Learn about environment
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Physical
Social
Emotional
Political
Professional
Hospital – bureaucracy / politics
economic
• But.. You’re not just a new staff member, you’re a new profession
where colleagues don’t have experience working with you (not as a
person, but as a professional)
Who should deliver
clinical exercise programming?
A healthcare professional that is trained in both
exercise and oncology
CSEP - Certified Exercise Physiologist
Registered Kinesiologist
Other Health Care Professionals?? (MD, PT, OT, RN)
Are Rehabilitation Approaches Similar?
•
Cancer rehab is similar to other types of “classic” rehab
Patient experiences life changing event
New impairment (Spinal cord, Brain injury, etc.)
NEED rehab interventions to improve Function and QoL
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For cancer survivors:
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sometimes treatment is ongoing…
There is prognostic uncertainty (progression, secondary cancers, death)
Different cancers and treatments affect different systems (all cancers/treatments are not the same)
High potential for multi-system impairment in any case
Integrating into an Established Clinical Team
Medical Director
• Medical Oversight
• Clinical ‘Final Say’
Occupational
Therapy
Physiotherapy
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Screening
Physical Ass’t
Impairmentbased rehab
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Screening
Occupational/
activity-based
Assessment &
intervention
Return to work
Massage
Therapy
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Lymphedema
ass’t and
treatment
Massage
Kinesiology
Other
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Psychology
Social work
Research
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Screening
Physical Ass’t
(for exercise)
Some
Impairmentbased rehab
Exercise Rx &
class delivery
Not your average RKins: Creating Expertise
Training:
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ACSM – “Cancer Exercise Trainer” (Webinar + Exam, must have based ACSM certification)
U. of Northern Colorado Cancer Rehab Inst. – “Cancer Exercise Specialist”
Wellspring – “CancerSmart Exercise” (exercise and rehabilitation focus)
University of Calgary / Thrive – Cancer & Exercise
Experience:
•
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Volunteer
Student Internships
Ongoing Learning:
• Rounds, workshops, webinars, mentors
Cancer Survivor Function Continuum
Severe Impairment
Highly Functioning
Interprofessional Approach
Impairment Driven Exercise
Exercise for
Performance Optimization
• Primary Clinician: MD/PT/OT
• Primary Clinician: RKin / Ex Phys
Impairment Examples
SOB
Limb dysfunction
Dysphagia
Amputation
Speech impairment
Impairment Severity
Lymphedema Erectile dysfunction
Frozen Shoulder Urinary Incontinence
Body Image
Fatigue, Pain, Neuropathy, Psycho-social dysfunction, muscle atrophy,
secondary osteoporosis
Breast
Prostate
Lung
Sarcoma
H&N
Failure to Address Needs
• Poor physical health reported by ¼ of cancer survivors
• Observational study (n=529): 65% of cancer survivors had
modifiable impairments that could be helped with
physiotherapy and occupational therapy
• Only 9% received rehabilitation services within 12
months
Scand J Work Environ Health. 2013;39:76-87; Cancer. 2015;
121: 623-630;
J. Geriatr Oncol 2015;6(3): 194-201
Scope Experimentation & Evolution
Clinical Activity
Physio
Medical screening
Cardiorespiratory screening
Flexibility / ROM
Aerobic fitness ass’t
Muscular strength ass’t
Joint mobilization
Axillary cording treatment
Aerobic training
Resistance training
Balance testing
Triaging
Lymphedema measurements
Lymphedema care
RKin
The Role of the RKin in Oncology
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Cancer-Exercise / Rehabilitation Clinician
Exercise Specialist
Counselor
Listener
Researcher
Friend / confidant
Student
Collaborator / Team player
Challenges
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Interprofessional inexperience on both sides
RKin role new to many the ancillary services (e.g. EMR)
Establishing trust
Difference in training
– Clinical training is a byproduct of experience, not often
formally integrated into undergraduate experience
• Disparity/inconsistency in employment status
– compensation – job review
– Full-time vs. casual/temp p/t contracts
Facilitators
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Research
Kin council
Focus on the model of care
Additional exercise-related opportunities
Personal and professional growth
– Interprofessional Education (IPE)
Lessons Learned
1.
2.
3.
4.
Focus on the big picture
The system (& people) can & will evolve
Huge opportunity to do something new
Trust is as important as you think.. And even
more important than that
5. Formalized IPE is (really) needed
Thank you.
Questions?
e. [email protected]
w. ellicsr.ca/en/clinics_programs/we_can
t. @DR_SantaMina