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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 – – – – – – – 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] 250 200 150 100 275 in 2015 50 0 1945 1960 1963 1967 1969 1976 1977 1983 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 # of publications 300 …150 in 2016 so far Year • • • • • • QOL Physical function Appetite Immune system function Cardio-pulmonary function Depression & anxiety • • • • • • Sleep Bone Health Body Composition Hospitalization Treatment Completion Fatigue • • • • • • Pain Postoperative LOS Social roles Self-efficacy Coping Tumour cell growth • • • • • • Insulin sensitivity Concentration Lymphedema Functional mobility Sexual function Survival Exercise Trials @ Princess Margaret • • • • • • • • 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, – – – – – 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: • • • • 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 • • • • 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 • • • • • 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 • • • • • CV Fitness • 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 – – – – – – – 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 • For cancer survivors: – – – – 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 • • • Screening Physical Ass’t Impairmentbased rehab • • • Screening Occupational/ activity-based Assessment & intervention Return to work Massage Therapy • • Lymphedema ass’t and treatment Massage Kinesiology Other • • • Psychology Social work Research • • • • Screening Physical Ass’t (for exercise) Some Impairmentbased rehab Exercise Rx & class delivery Not your average RKins: Creating Expertise Training: • • • • 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: • • 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 • • • • • • • • Cancer-Exercise / Rehabilitation Clinician Exercise Specialist Counselor Listener Researcher Friend / confidant Student Collaborator / Team player Challenges • • • • 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 • • • • • 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