Transcription:
Cancer Rehabilitation

Melanie Cole (Host): Welcome to Back to Health, your source for the latest in health, wellness, and medical care, keeping you informed so you can make informed healthcare choices for yourself and your whole family. Back to Health features, conversations about trending health topics and medical breakthroughs from our team of world renowned physicians at Weill Cornell Medicine. I'm Melanie Cole joining me today is Dr. Nasim Chowdhury, he's the medical director of cancer rehabilitation at Weill Cornell Medical Center, an assistant attending physician at New York Presbyterian Hospital, and an assistant professor of clinical rehabilitation medicine at Weill Cornell Medical College, Cornell University.

And he's here to highlight cancer rehabilitation with us. Dr. Chowdhury, it's a pleasure to have you with us today. I'd like you to start for the listeners telling us a little bit about cancer rehab. What is it and who is it for?

Dr Nasim Chowdhury: That's such a great question and thank you for having me. What I practice, which is rehabilitation medicine, generally, the way we like to describe it is as a functional specialist. Right? So what that means is you take a group of people, and you maximize your function. That may mean an elite athlete, in fixing their workout regimen, or that may mean treating someone who's had a devastating stroke cause rehabilitation medicine.

It's all about the medicine of making people function better. When we talk about cancer rehabilitation, that's actually looking at folks who are affected by cancer or its treatment, and figuring out a way to make them function better. And function is such a broad term. Really what I mean by that is the way they move, the way they think, anything that makes them different than the person they were. My job is to address those things that are different and try and improve them.

Melanie Cole (Host): That was an excellent description. So let's talk about the benefits of this type of program both before and during, and maybe even after cancer treatments. Because we've heard Dr. Chowdhury. all these years about rehabilitation and prehab for surgeries, for ortho and any of these others, but for cancer people haven't heard so much about it.

Tell us a little bit about the benefits of these type of programs. Really what are they doing for the patient while they're going through these treatments?

Dr Nasim Chowdhury: The reality is the healthier you are going into your treatment, the better you're going to look afterwards. Now that does not necessarily mean the treatments are going to be more effective, but we do know when you treat cancer, you're oftentimes given very toxic chemotherapy. You're given radiation sometimes, there's often surgery involved. All of those things can have negative effects and do have negative effects on your body. If you're in better condition going into those, frankly, devastating treatments at times, you look much better on the other end.

And so that's why the fact that prehab hasn't really been the focus in cancer, is something that those of us that treat these sorts of patients are very passionate about. So there's no doubt that prehab is critical for patients with cancer. And I think getting plugged into services and treatment as soon as possible is appropriate.

Melanie Cole (Host): So then what are those services? Tell us a little bit about what cancer rehab really entails. Is it physical therapy? Occupational? Is it nutrition counseling, fitness activities. What's really involved in this type of a program?

Dr Nasim Chowdhury: Great question, and you actually nailed it. All of those things, all of the above are and should be involved. So as a cancer rehabilitation physician, I work with a massive team of people. I have to be familiar with the treatments that the oncologist used because different chemotherapy drugs will have different effects on the body. I have to be familiar with the dosages of radiation used and where it was used because that can have its own effects. In terms of surgeries, being familiar with how the procedure was done and what parts of the body were affected during the surgery is also critical.

Because when my oncology colleagues, whether it's surgical oncology, medical oncology, or radiation oncology, when they refer patients to me with particular problems, if I'm not able to sort of parse out where their symptoms are coming from, I won't be able to treat the patient effectively. As an example, if I sent a patient with left arm pain in swelling. It's important for me to know the sorts of treatments that were done, what kind of surgery was done so that I can best come up with a treatment. That may include getting an ultrasound to make sure there's not a blood clot, for example.

It may mean reviewing the surgical notes to see if there were a lot of lymph nodes taken out and that actually then helps me come up with a treatment. Sometimes that's medications, sometimes that's injections. Sometimes it's ordering more tests, but nearly invariably that means involving physical therapists or occupational therapists or depending on, if the brain is affected, potentially a speech and language pathologist. A lot of our cancer patients have lost weight and they lose appetite and they may have mouth ulcers.

They may have a whole slew of reasons that they've lost a dramatic amount of weight, certainly in that setting, involving a nutritionist is very important. I have a background in, nutritional science as well, but generally speaking, the more disciplines you involve, the better the care is for your patient. Simply because cancer treatment affects people head to toe psychologically, physically, emotionally. And so I, think the best care of your patient in this case means involving as many members of the team as.

Melanie Cole (Host): Well, I agree with you there. And as an exercise physiologist, I know that that multidisciplinary team is what is crucial because everybody brings something to the table to really help this patient with the quality of life. When, Dr. Chowdhury in the course of diagnoses to pre-treatment and during treatment and after when, in the course does all of this start, does it start right at diagnosises? Well, let's talk about your mental health with diagnosis and all of those things. What's your support system. When does all of this start?

Dr Nasim Chowdhury: The reality is cancer and its treatment is very, very individual to the. Every person reacts to it differently. Every person responds to chemo or radiation or surgery or all of the above differently. Everyone has a different medical history that may increase or decrease their risk of certain issues coming about. And so frankly, I think seeing a rehabilitation physician, soon as possible after your diagnosis makes a lot of sense. We oftentimes serve as the quarterback and we can help patients identify, who else should be involved in their care.

We can take the prehab piece as an example. Insurance does not cover prehab. We know this. But you and your rehabilitation physician can figure out a way to work around the limitations that are given to us. So, as an example, if I know my patient is due to have her breast cancer removed, and I know that oftentimes with breast cancer surgery, People's posture change. They lose mobility in the shoulder. There are a lot of pain issues in the chest wall and in the shoulder that occur, I can perhaps focus on an old rotator cuff injury and help set the patient up with physical therapy or occupational therapy, even prior to them getting their treatment.

And so to answer your question, it's never too early. Even if it's too glean basic knowledge from these different disciplines, knowledge is power and going into your treatment better informed is always ideal.

Melanie Cole (Host): Certainly is now let's talk about some of the other therapies we haven't mentioned, because one of the things that breast cancer patients have learned about lymphedema treatment. There's always medication and certainly pain management is kind of new to the picture, but so important in what a burgeoning field that whole thing is. But we're even hearing about ultrasound guided injections for pain. Tell us a little bit about some of these other forms of therapy we may not have been familiar.

Dr Nasim Chowdhury: Certainly I perform ultrasound guided injections in my every single day. The way that these injections are done is that an ultrasound machine, which has no radiation, doesn't hurt allows us to guide a needle to the exact target that we want. It is a much better way of doing injections than using these sort of old school method of poking around and hoping that that's the right spot. The truth of the matter is if you don't know what you're treating, sticking a needle in, it is probably not appropriate. And that's where an evaluation with a cancer rehabilitation physician is very important.

There are myriad examples of when an ultrasound guided injection, for example, would be reasonable. Let's use arthritis as an example, there are many cases in which I'll have patients sent to me by my oncology colleagues with knee pain. They've had treatment for breast cancer, obviously looking at imaging and just knowing the history. I can say pretty confidently that this has nothing to do with your breast cancer. You have swelling and fluid and pain in your knee. I don't think it's unreasonable to give you an ultrasound guided shot of cortisone, for example, or drain the knee, using an ultrasound for guidance.

Alternatively, there are patients who after the treatment of their breast cancer, for example, are given hormonal drugs and those medications can oftentimes cause pain and swelling around tendons in the wrist. So that's related to the cancer treatment and those areas are amenable to injections as well. It really depends on getting a clear diagnosis and injecting at that point. So really seeing a physician who is familiar with these diagnosis is very important.

Melanie Cole (Host): Well, it certainly is. What an interesting field that you're in. How does this work for the patient? Because they're going to maybe chemo or radiation they're dealing with possible surgeries. How do they continue their normal routines while doing these types of rehabilitation services? Does this take up just all of their time? How does this work for the patient?

Dr Nasim Chowdhury: You'll hear me say over and over, it's such an individual process only because someone who had, for example, their prostate removed and lymph nodes taken out in their groin, will have a totally different set of problems than someone who had a brain tumor that was removed. And so there's never an approach that will be appropriate for every patient. But generally speaking, we do know that not only is the treatment of the cancer time consuming, doing all of the work to address the issues that come about from the treatment is also time consuming.

Generally speaking, you're looking at about once or twice a week of physical therapy plus or minus once or twice a week of occupational therapy, plus or minus potentially once or twice a week of lymphedema therapy. Plus an evaluation or an appointment with a nutritionist, plus a potential injection or evaluation, or follow up with your rehabilitation doctor. Plus seeing your oncologist and getting blood work and getting follow up imaging. it can really be overwhelming. And I think having a great support system is very, very helpful.

I think involving family as much as possible is critical. And I think patients advocating for themselves and having these sorts of discussions is critical. There's absolutely no reason. That a patient shouldn't feel comfortable asking any of their doctors or their clinicians, a question about returning to their normal life. If they're worried about whether an activity is safe or not, ask. I think there's nothing that beats, a patient advocating for themselves when it comes to outcomes.

Melanie Cole (Host): 100% agree. Being our own best health advocate is really the way to get the best care and working with our doctors in that shared decision making is so, so important. And I'm so glad that you mentioned Dr. Chowdhury the families and how that support system is really important and how they can get involved. As we wrap up, how does someone with cancer access your cancer rehabilitation programs? Is this referral, how does that all work? And give us your best advice about why cancer rehabilitation programs are vital and so needed and important for cancer patients to really help that quality of life.

Dr Nasim : So it is a challenging landscape. We have to acknowledge that upfront. There are not too many institutions that have cancer rehabilitation physicians. There are also institutions where physical therapists or occupational therapists may not be as familiar with treating patients with cancer. There are many institutions which unlike ours, don't necessarily have integrative health services or mental health services or clinicians who treat cancer patients daily. I think the best place to start is with your oncologist.

The NCI or the National Cancer Institute, has designated cancer centers. These are centers that are known to provide a broad range of clinical services with a very strong research background. Those institutions will have a slew of services available and they will also have great outreach and just to make it as easy as possible for the patient. That's actually something that patients can look at online when selecting an institution to get their treatment at. For those that are not necessarily close to these sorts of institutions, the absolute best place to start is with your oncologist.

And alluding to what I had mentioned earlier, in terms of advocacy, no one knows your body better than you do. If something feels different, you absolutely should feel empowered to bring it up to your doctor. But generally speaking a conversation with your oncologist should involve a couple of questions. The first question should be, hey Doc, what sort of rehabilitation services are available? Do you have a network of therapists that are comfortable seeing patients with my diagnosis? Is there a rehabilitation physician, if they're not a cancer rehabilitation physician, that's fine.

Is there at least a rehabilitation physician who's trained in. Rehabilitation and in optimizing someone's function? Is there someone that you work with or know in the area that's readily available? I certainly think that's the best place to start. some independent research is always helpful. Google's a very powerful tool. Even if your oncologist isn't familiar, Googling rehabilitation physicians or cancer rehabilitation doctors is certainly helpful. With the explosion of video visits that may even mean you're able to have an evaluation by a physician who's geographically distant from you.

Those would be my suggestions. And here at Weill Cornell Medicine, I've never met a larger group of physicians that are more open to listening to their patients. we have a slew of oncology services and if there are ever any questions, I know my colleagues and I are very, very open to answering any questions you may have.

Melanie Cole (Host): Great advice, Dr. Chowdhury what an interesting podcast this was and really, really informative. I thank you so much. Gosh, you gave us a lot of really usable information. Thank you for joining us and sharing your incredible expertise. And Weill Cornell Medicine continues to see our patients in person, as well as through video visits. And you can be confident of the safety of your appointments at Weill Cornell Medicine. That concludes today's episode of Back to Health. We'd like to invite our audience to download subscribe, rate, and review back to health on Apple podcast, Spotify and Google podcast. And for more health tips, go to weillcornell.org, search podcasts. And parents don't forget to check out our Kids' HealthCast I'm Melanie Cole.

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