How Physical Therapists Can Support Patients on Immunotherapy

0:00 You're listening to the PT Pinecast, where smart people in healthcare come to make noise. Here's your host, Jimmy McKay. All right. It's a new, I should say new, it felt new a couple of years ago when we were talking about it, but this is a PT specialty that's gaining momentum. And it's about time. It's the newest thing. It's been around for a while. While millions of people are living with or beyond cancer, far too few know that physical therapy can be a game changer in their recovery, in their function, and in their quality of life. But today we've got a little CSM preview like we've been doing that isn't waiting for the referral.

0:40 They're building the case for why every PT program, every clinic and every physical therapist needs to step up and meet the needs of this population. From classrooms to clinics to social feeds, conferences and clinical practice, these guests today are helping change the narrative. So let's welcome Amanda and Scott to the show. And Steve, Steve's here in spirit is what we'll say. Steve's been on the show before. Amanda, Scott's been on the show before, so I'm going to say welcome for the first time here to you, Amanda. Thank you. And you're in the Lone Star State of Texas. Real quick, what's your superhero backstory, just to give the audience of context about you and your career?

1:23 Okay, so I went to, as Scott likes to say, the greatest physical therapy program in all the land in Ithaca, New York. It's gorgeous. I'm very proud. Oh yeah, it's gorgeous. Not this time of year. go over the summer, especially if you like wineries and waterfalls. But so I went there and everybody goes into PT school, maybe thinking athletics or some grand big picture with no inkling of oncology care. I graduated even in twenty twenty two. And so that's relatively recently and still didn't really know much, especially when I went in.

2:04 So then over COVID they did a really good job of like keeping us engaged. They did some speaker series of the different specialties in physical therapy. So then in enters Scott on zoom does a great job explaining, you know, about oncology care. And I'm like, wow, that's a really cool niche kind of fills my little like nerdy void. And he said, oh, if anybody wants to come shadow me up in Connecticut, I'm like, okay, that's not too far from New Jersey where I'm from. So I went to go shadow him at least twice, uh, once in a survivorship program and then once in just a clinic day.

2:45 And that was it for me. I just decided that that's what I wanted to pursue. So I worked, um, in the New York area after college was like kind of starting more of like their oncology program there. They had a really great like breast program. but nothing really coming from medical oncology. So I was a big advocate for that there and then moved down to Dallas, Texas, started working at UT Southwestern, which has an amazing oncology rehab program. We have like a physical medicine rehabilitation doctor. So been doing a lot of that here. power of story scott we've had you on the show before but i'm smart enough to know podcasting is like radio just because you told a story a couple years ago doesn't mean the same people are listening right now so how's that number one my first question is how'd that make you feel that you jump on just a zoom call right with ithaca right great program go bombers uh and then someone that story lands That's number one, but number two, they took a step.

3:45 They liked it more. They took another step. So first I want you to do this, talk about that. And then I want you to tell the audience who may not have any idea who you are, even though you've been on the show before, what that story or a quick snapshot of what that story was. Yeah. I do think being a clinician, being a PT now for a long time, I do feel that it's my obligation to give back to the students. I realized that being an oncology physical therapist, like Amanda said, It is kind of a niche thing, even though there are twenty million cancer survivors living in the United States. So I would argue that it's not necessarily niche. But from a programmatic perspective, when we talk about DPT programs, it is rarely, if at all, ever covered.

4:34 So that was really cool that I mean, I really, you know, I give this talk every year to Ithaca because it's my way of giving back. And I'll get into that more in a second. And I always say, listen, you know, I'm an open book and I want you to learn. You know, the best thing I can do at this point in my career is to help bring somebody else into this realm. So, you know, this is my cell phone and this is my email. And, you know, I love having students. They are the future of our profession, Jimmy. You know, so I'm closer to retirement than I am being a new graduate. So, yeah, so when Amanda reached out to me, she was like, yeah, like, I'm willing to make a drive, you know, yeah, I'm going to have to drive up to Georgia to Connecticut to hang out with you.

5:25 And, like, awesome. Also, you know, to the power of our alumni association, and I think everywhere we go, Jimmy, I know that you've been really, you know, connected with your alumni association as well, you know, with your PT program. So I think that... Right there, you know, just the power of those of us that have graduated, wherever we've graduated from, you know, to be able to give back, you know, to our universities is great. So it was really, you know, it was really... it felt really good yeah to have Amanda reach out to me and I've had other students do that now too where they say listen I want to see what it actually looks like like it's one thing you know to have the PowerPoint but what exactly do you actually do with these patients like and how is it different and when they come and they've observed me in clinic they realize that you know it's just PT right It's just the extra twenty percent layer of knowing what the drugs are and knowing what these side effects are from the drugs and being able to read that chart and decipher it and be able to predict what those adverse effects are going to be.

6:36 So that way we can put on our PT hats and say, oh, that chemotherapy in particular can cause peripheral neuropathy. If that person can't feel their feet because of neuropathy, they're a falls risk. So what do you do? Falls prevention. Any PT could do fall prevention. It's just a matter of understanding why we have to do fall prevention for that patient. And why would persons with cancer and who have survived cancer, why is that particularly, why is that something important to you? So I was diagnosed with cancer when I was in PT school. I was in my last year of PT school at Ithaca.

7:17 And you could say that I didn't really fit the profile. I ran cross country and track for my four years there at Ithaca. And I never drank, and I never smoked, and I never did drugs. I was always the designated driver for all my friends and all my teammates. And there was also no family history of cancer. And so I never would have expected in a hundred years that I'd be diagnosed. But as a twenty two year old going into his last year of PT school, that's what happened. And, you know, again, the why I feel so strongly about our program at Ithaca is because my professors stood by me and my classmates stood by me and my professors said, We're going to get you through this.

8:05 You are going to graduate with your cohort. You've been with your cohort all these years. You're not going to go back. You're not going to stay back a year. You will graduate with your classmates. And so that's why I always feel that this is a small thing that I can do to give back to my program. And that talk even kind of morphed over the years. you know, initially I'd go back and I would just tell my story. And really it was almost like a PSA of, Hey, I was and I got cancer. So start doing yourself exams now. Um, And then as I got more and more into oncology rehab, then it morphed more into the actual oncology lecture.

8:48 You know, what is oncology rehab? What do I do? And why do these patients need care? In addition to telling my story. So, yeah, so Amanda, you and your classmates kind of heard that version of it, you know, both the didactic piece of it, but also the personal piece of it. So our audience obviously is not public facing. It's pretty much internal to the profession. How do you answer this when fellow PTs find out, this is for both of you, hey, this is the type of patients that you work with. How do you answer the question, why do people with cancer need PT? Why are so few getting it? I mean, even Amanda, you said in the middle of PT school, this wasn't something you went into and expected to be there, but once the rationale was there, I don't think you could shout this enough just because people like you understand this deeply.

9:39 Why? What is the answer to that? Why do people with cancer need PT and why are so few people getting? I think that I mean, I get this question a lot, usually not so much like from physical therapists, but like, obviously, yes, mostly from people like that are not in health care, be like, what do you do with cancer? And I'm like, everything they need so much. But from my peers, it's more like, well, OK, you know about the human body, obviously, and the movement systems and everything. Let's talk about what cancer treatment does to the human body. And I explained these things are so important. These things save the patient's life.

10:21 And previous, and Scott can attest to this because he was a part of it as it was growing. But previously it was like, oh, no, like leave these patients alone, let them rest, let them recover. OK, well, now we have so many cancer survivors because of all these amazing treatments and they need to get back to doing things that they were doing before, whether that's child care, whether that's their job, whether that's caring for aging parents. So what are things that we can do that help them decrease the effect of neuropathy, decrease cancer-related fatigue, decrease, you know, help people sleep better? If you're not sleeping well because of, you know, like radiation fibrosis to your shoulder or shoulder pain and scapular dyskinesis, how can we help this person sleep better so they can function better during their daily life?

11:13 With neuropathy, how can we help to decrease their neuropathy so that they can sleep better, so they can walk better? to decrease the risk of falls. I'm also studying for the specialty exam right now and just going through the textbook, it says something and don't quote me, numbers are not my strong suit, but something like forty percent of men that take androgen deprivation therapy for prostate cancer will have a fall and a fracture within the first few years of taking that. So we know what these patients are going to go through because we know the side effects of the treatment. So how can we help them during and after? or even getting prepared for it. Sure. Yeah. And to kind of answer the second half of that question, Jimmy, I think the, you know, I think there's still a lot of misconceptions, you know, probably about, you know, or with our oncology colleagues, first of all, you know, again, if somebody has been practicing for thirty years, thirty years ago, that's what the evidence said.

12:10 Let these patients rest. Don't let them do anything. They need to conserve their energy while they're going through treatment. So that's what they got in medical school, oh, thirty years ago. And so that's probably what their mindset still is today. I'm noticing that I'm getting more and more. Most of my referrals are coming from younger oncologists because they're getting it more in in med school. And and again, we have the evidence now In twenty twenty six, we have all this evidence that shows the benefit of exercise. And so now I think the oncologists are starting to come up with that. But we're going to have a whole other conversation about, you know, we need to make this easier.

12:53 Right. Like, Jimmy, we've talked about this before. You talk about this all the time, Jimmy, the easy button, you know, the target like, you know, or Staples easy button. We need to make it easier for these oncologists. and these oncology nurses to get these patients to us. They are dealing with so much. Exercise and rehab is not the first thing that's on their minds. And so we need to be able to build, if you're in a big academic institution, like use Epic to our advantage, like build it into the order set to make it easier for them to make that referral. They just have to hit the button. rather than fill out all the referral stuff.

13:34 That's where a lot of it gets lost, honestly. You've said before that oncology, physical therapy, landscape is constantly changing. What's new What's new that PTs need to know? Maybe something that even if they thought they were on the cutting edge a year or two ago, what's something that's a big disruptor that maybe PTs still, even if they're ahead of the curve normally, that they don't know? Yeah, well, two things there, Jimmy. First of all, last year in twenty twenty five in the New England Journal of Medicine, kind of what I would consider the holy grail that we've been searching for for all of these years.

14:17 The challenge trial was published and it was this huge multicenter study had almost nine hundred patients with stage two or stage three colorectal cancer. And the intervention group exercise and they had supervised exercise programs and one of the big things too about this this trial was that these patients could do cardio they had to do forty five minutes of cardio three or four times a week but they got to choose the kind of cardio that they wanted to do so it could have been walking it could have been hiking it could have been biking gonna be kayaking And so they had these checkpoints with their physiotherapists and exercise physiologists twice a month for one year.

15:01 And then they can continue to still have touch points once a month for an additional two years beyond that. So three years total, they had somebody checking on them to making sure they were adhering to exercise and rehab. And the researchers found that Those that exercise decrease the risk of recurrence of the cancer of colorectal cancer by twenty eight percent and decrease the risk of death by thirty seven percent. I'm a huge fan of not dying. So that sounds good. Right, right there. Just by exercising, you decrease your risk of death by one third.

15:42 And that's just the exercise piece of it, right? But those patients were monitored. They had accountability partners. They also got to choose that type of exercise. And then the kicker out of this study, out of all this great data, was that when they did an even bigger analysis and they put exercise up against chemo, a very particular chemotherapy drug, oxaloplatin, they found that exercise, the patients who exercise, it was more effective than the chemotherapy was. So that's it. We have the proof that exercise and rehab can be better than chemo.

16:24 improving overall survival for our patients so that's one big thing that just came out less than twelve months ago the other thing and this is kind of you know alluding to the the talk that amanda steve and i are going to do at csm is the the increase in availability and the development of immunotherapy Immunotherapy is different than chemotherapy. Immunotherapy is more targeted therapy to try to turn the immune system on to try to identify the cancer cells and go after them. And again, new data that just came out in January of twenty six.

17:07 The American Cancer Society always releases updated stats every year. for the first time, the overall cancer survival rate, if we put all the cancers together, has finally eclipsed seventy percent. So that's a big deal, right? That is a big deal because it was not that twenty, thirty years ago. And we specifically saw an increase in survival in some of the harder cancers that are out there, like melanoma, that survival rate almost doubled. The survival rate of patients with liver cancer almost tripled. And you could probably say that immunotherapy had a big role in that because immunotherapy was not readily available and readily used, in the treatment of a lot of these types of cancer.

18:00 And now they are. And so we're seeing an improvement in overall survival by adding immunotherapy to some of the traditional treatments such as chemotherapy and radiation therapy. So we know better, it's just time to make sure we do better, right? We've been yelling for research left and right, now we have it, now it's time to execute. Well, this brings us to your talk at CSM, doing a lot of these sort of hype videos, which I think is good. If you're gonna huck yourself all the way out to LA, make sure you understand what's on the menu, because I wouldn't want you to miss it. So Thursday the twelfth, ten thirty to noon, nice in the middle of the day, not too early, not too late, smart.

18:42 Um, I like the title. I don't know if I'm saying it right. Pronounce it for me. Sibs, nibs, and mabs. Oh my. And identifying opportunities in immunotherapy rehabilitation. I gotta be honest, sibs, nibs, and mabs. I don't know what they are. Help me out here. Yeah, so I think that that's the whole point. The sibs, mibs, and mabs, that is the tail end of a lot of these drugs. And again, as a student, as a new clinician, even a seasoned clinician, but you're getting into oncology rehab, or you're working in a sports rehab center, and you have this patient come in, and you look at their chart, and you see these things.

19:30 You're like, what? and God's green earth are these drugs. And so that's why we wanted to demystify that. We wanted to talk about what is immunotherapy and the effects of immunotherapy on the body. And then what we can do as PTs to make sure that we're keeping our patients healthy and keeping them moving and potentially even helping to help enhance the effects of immunotherapy as they're trying to work towards getting rid of the cancer. Amanda, what do you hope people who walk out of your talk are able to do?

20:11 What is the goal? What should they look like? What should they feel empowered to do? What's the change happen in ninety minutes with you guys in L.A.? ? Yes. So I, something that I really want to emphasize is that even though like the title of our presentation, not that it seems daunting, I think I love Scott's, uh, you know, idea of bringing in lions, tigers, and bears. Um, but it's not just for seasoned oncology PTs. Um, I think that's a lot of the audience that we're going to capture. Um, but. I want anybody to be able to come to our presentation and know what are the possible side effects that they should be looking for, for patients that are receiving immunotherapy, because it could be somebody that's coming to you in an ortho clinic for a knee pain.

21:05 It might not be somebody that's going to a specialized cancer clinician. They could have either be on immunotherapy because people are on it for longer periods of time, or they have something big like a CAR T cell therapy. And we'll get into that in our presentation, but it might not be somebody that looks super ill that needs like specialized cancer care, or just in your community, you might not have a specialized oncology clinician. So it could be somebody going to any office for any problem that may have a history of immunotherapy or may be currently on it. So a big thing in our presentation is what are these side effects?

21:48 How do they impact the human movement system? That's Steve's whole thing. It's how do they impact the human movement system and what like emergencies are you looking out for? Because some of these side effects can be life threatening, but some of them are very mild. So we're going to go over the mild ones, the life threatening ones, how to keep an eye out for them in your practice and how to discuss these with your patient. Yeah. I do want to say thanks to Empower EMR. If your clinic's stuck in an EMR that slows you down, you shouldn't have that EMR. Empower gives you speed, clean workflows, and features PTs actually ask for. Better notes, faster documentation, smooth operations. All wrapped in customer support that doesn't ghost you.

22:30 EmpowerEMR.com. EmpowerEMR.com. Got to pay the bills here, guys. Otherwise, we don't keep the lights on the podcast. If someone says, I feel a little bit unprepared, Why should they come? Amanda just sort of touched on it. Is this going to be too over someone's head or is this pretty available and accessible? Like we want those advanced courses, right? Just who's this right for? Who should walk in and sit down? Yeah. And as Amanda, as you were just alluding to, I think any student and any clinician, whether they're an oncology specialist or not, they should walk in because we hope to be able to answer those questions so that anybody who walks in then walks out nine minutes later and says, oh, okay.

23:22 You know, these immunotherapies, these sims, mibs and mabs, they're not that scary. Right. Because, you know, Amanda, you just said it like not every clinician is an oncology clinician. But again, with twenty million cancer survivors living in the country. This patient could walk into your traditional mom and pop outpatient sports clinic in East Tumbleweed, Kansas. But you have to be prepared for that. And so we want all clinicians and we want students, because I guarantee that's not like we talked about earlier. A lot of this is not being covered in DPT programs.

24:02 I would love students to show up to this so that that way they feel empowered when they go out on their clinicals. They could be the ones that are teaching their CIs what this is. I like myth busting. I like correcting at least. So this is for both of you. You each get to pick maybe one. What's a myth about either oncology, physical therapy, or immunotherapy? What's one myth? that you find yourself sort of saying, well, yeah, okay, yes, but maybe they're not completely off, but maybe it's a couple degree course correction. I'll give you each an opportunity to correct one myth or update or drop a well actually about oncology PT that other clinicians need to stop missing the mark on.

24:52 Well, I think one of the things that I would consider here, and maybe we're going to get into it in our talk specifically, is that immunotherapy is easier than chemo because it's not chemo. Right. Like we all know we have a pretty good understanding, even if you're not an oncology PT, like if you've had a loved one go through cancer treatment, like you're kind of used to seeing, you know, kind of the telltale signs of what chemo is, you know, the hair loss and the nausea and the vomiting and the fatigue and all that. And so you look at immunotherapy and you say, well, that immunotherapy is not chemotherapy. Right. It's not designed to kill all these all the cells at different points of their development. so there's no side effects so it's got to be good for you but amanda you were talking about this that there are mild side adverse effects and there are some pretty significant side effects from immunotherapy and as clinicians we might be the ones who see that for the first time in these patients and we have to know what that is recognize it then be empowered And to run that up the chain to the oncologist and say, hey, I saw Mary Jane in clinic today and this is how she presented and I know that she's on, you know, her luzumab.

26:06 So I think you need to reach out to her and get her in clinic and do a full, you know, full workup of her. So I think that's one of the myths that specifically for our our talk at CSM to try to bust that myth that just because it's not chemo, that it's a breeze. All right, Amanda, you got to follow that. What's the thing that you that you know, what's the what's the rock in your in your flip flop that you'd like people to get right once and for all? Man, I have so many things in my brain. I think an important thing that Scott just brought up about pembrolizumab. So if you've ever heard of Keytruda in a commercial, I'm sure everybody's seen the Keytruda commercial.

26:49 You know what immunotherapy is. That's pembrolizumab. So it's much more common than you think. There are a lot of these drugs out, even though they're relatively new, they're being used a lot, like Scott said, and they are responsible for some of the increase in cancer survivors. So there's that. Jimmy, you do know an immunotherapy, but, um, I think a rock in my shoe is that number one, cancer rehab is sad. Right. So a lot of like, man, like, how do you do that? Like, you know, I'm like, Oh, because so many people are surviving. I mean, of course I do have some patients that are stage four more end of life.

27:31 It's equally as important for them. Um, but I have so many patients that are surviving and we're doing prehab and it's not just death and dying, but I think that the most important thing that I do want to bring up is that. PT belongs in hospice and palliative care. I think there's a misconception, especially on an inpatient side, because I've done that as well. When you go into the patient's chart, you see a palliative or a hospice note and you're like, Oh, defer. Get that patient off my list. And, um, there's another really awesome CSM presentation about. You know, palliative care. Um, I believe that's Chris Wilson's doing that one.

28:12 Um, so PT belongs in palliative care and palliative care is not just when the patient's dying palliative care, especially for patients for cancer patients is often involved from the point of diagnosis to help with comfort, but it's not just comfort care and dying. it's helping them. And there are ways that physical therapy should be involved in palliative care. And just because like, let's say a patient was, you know, more end stage, you know, you weren't expecting them to improve. You're expecting a decline. That's an even more important reason why physical therapy should be involved in And there are ways to write a plan of care and write goals for maintenance therapy where you're not saying, oh, the patient's not approving, so I have to discontinue care.

28:59 No, you should be involved to help prevent decline, to help prevent increased reliance on caregivers, to help them maintain their function and independence through their end of life, which is such a huge quality of life thing. Yeah, I mean, I'm so glad you brought that up because, you know, and right there, what you were talking about, like goal writing for that patient who's at end of life care, like one of the biggest things that we could do as rehab professionals in that setting is caretaker education. Because if the caretaker, you know, is trying to do transfers for that patient, you know, trying to do bed to commode transfers or whatever that might be, and the caregiver throws their back out, They can't care for their person.

29:46 So there is always a role for physical therapy, especially in that setting. So Amanda, thank you so much for saying that. That's the rock in my shoe. You each get one shot, one opportunity. Don't throw it away. Someone who's listened to this episode to this point and they're going to get on a plane or they're on a plane right now as they're listening and putting their, their schedule together for CSM. What's your pitch? What's your one or two sentences and why they need to come to your talk? When they come to our talk, they are going to feel empowered that they can treat any patient with a history of cancer.

30:26 We want to be able to demystify not just immunotherapy specifically and its treatment in cancer, but we want to be able to demystify the whole aspect of oncology care and that any PT can care for anybody with a history of cancer. And they need it. Amanda, what do you got? I think that, yes, Scott, that's it as well. And we are also going to go over some cases in our presentation. So I'm really excited about that. And it's going to show that there is a huge opportunity for prehab, not just in immunotherapy, but in cancer care.

31:13 Because like I mentioned before, since we know roughly the route that these patients are going to take with their treatments, of course it changes as they monitor the disease progression, hopefully lack thereof. But since we know what they're going to be going through with the treatments and the medications that they're prescribed, how can we prepare these patients for what they're going to be going through? which then helps to improve their function. It also helps to decrease their anxiety about the treatments that they're going to be going through. And it also helps them move their body through it. So I think that highlighting prehab there and showing the opportunity for intervention at that point is going to be so empowering for physical therapists of any specialty, but also our oncology colleagues.

32:05 Sibs, Mibs, and Mabs, oh my, demystifying challenges and identifying opportunities with immunotherapy and rehabilitation. That is Thursday at CSM, ten thirty till noon. And that is in the oncology section. Last chance for what we call the parting shot. This is the parting shot. One last mic drop moment. No pressure. Just your legacy on the line. pressure whatsoever. Scott, we'll let you go first since you've done this before. Amanda, give you some time to formulate. Parting shot is just whatever your mic drop moment is, your soapbox statements. What's the last thing you want to leave with the audience as we wrap up?

32:48 I think we've already covered it, but I would say that use CSM. I would say my parting shot right now is use CSM to network. build your network, talk to people. It is absolutely a good thing to have a little bit of imposter syndrome, but check your imposter syndrome and go talk to somebody, go talk to a seasoned clinician, because I guarantee you, those of us that are seasoned clinicians, we want to talk to you. And again, like we let off, I'm already like way into my profession now.

33:30 I know that the future of our profession are students and new grads. Please come talk to me because you are going to grow this profession. And so use CSM as an opportunity to talk to somebody. Please come talk to me. That's Scott's parting shot. Please come talk to me. Amanda, what do you got? You can reiterate a point you did before or drop something new. Doesn't matter. What's your parting shot? Yes. So I'm going to piggyback off of what Scott just said. And so I am on the APT Oncology Students New Professional SIG. And we host a networking session where...

34:11 Anybody interested in oncology rehab, students, new professionals. We also have some really awesome seasoned oncology practitioners like Scott that always pops in. Chris Wilson typically pops in as well. So we are planning to have a really awesome networking session. It is Friday the thirteenth. Spooky. Nine thirty to ten thirty a.m. You will find that in the oncology section in the programming on the app. And we love to have people that are just kind of intrigued by oncology. They don't know much about it, but they want to learn more. They want to talk to other students, new professionals, even seasoned professionals about it and just, make the community grow.

34:58 So that's what we like to do. So I hope we need a better name though for next year. This is already locked, but students and new professionals networking session. I feel like with AI, we can come up. We will, we got to, we, this needs to be judged. We got to judge this and we'll do it for next year. Hey, thanks for doing what you do. Coming to a conference is a great networking experience, but the amount of work that you guys put together and put into these things is usually no small feat. A ninety minute presentation doesn't just happen. So thanks for doing this. Steve's not here, but Steve is a great friend of the show. So we'll see you guys in in L.A. and Anaheim in just a couple of weeks. And thanks for doing this. Thanks for having us. This is great.

35:38 Yes. Thanks, Jimmy. That's it for this one, but we're just getting warmed up. Smash follow, send it to a friend, or crank up the next episode. Want to go deeper? Hit us at pgpinecast.com or find us on YouTube and socials at pgpinecast. And legally, none of this was advice. It's for entertainment purposes only. Bulls**t! See, Keith? We read the script. Happy now?