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It’s not common to hear physical therapy and cancer together in a sentence, but Dr. Mary Lou Galantino and Dr. Nicole Stout are both adamant that we should hear this combination more often. Integrative physical therapy can significantly improve the lives of people who are undergoing cancer treatment or who have survived cancer and are ready to move on with their lives.
The survival rates of cancer have been steadily increasing over the past several decades and now sits at 68%. Which is an absolutely amazing improvement to see! However, most cancer survivors will go on to suffer from a chronic health condition that can lead to subsequent problems like psychological distress, higher medical costs, financial hardship, and increased need for healthcare services (1).
This is where Dr. Galantino and Dr. Stout believe that physical therapists and improved community support can make the biggest difference for in the world of oncology care today.
How can a cancer survivor or patient experience improvements through physical therapy? Well, it takes a concerted effort with an integrative approach. Fortunately, Dr. Ginger Garner and Dr. Joe Tatta’s book, Integrative and Lifestyle Medicine in Physical Therapy covers everything you’ll need to know about it. And Dr. Galantino and Dr. Stout co-wrote the Oncology chapter with Dr. Lisa Vanhoose.
There are many different types of challenges that someone going through cancer treatment or surviving a cancer diagnosis might be dealing with. Some of the more common ones include:
Physical therapists are skilled to help treat people who struggle with these conditions but oftentimes, people with cancer are not given the option or consideration to seek integrative physical therapy services during their cancer journeys.
Are you currently struggling with cancer? Do you know someone who is? Are you a physical therapist interested in what role you may play in cancer rehabilitation for the people in your community?
Then we invite you to listen or watch our latest podcast episode.
Dr. Mary Lou Galantino is a Distinguished Professor at Stockton University, where she coordinates a Holistic Health Minor and teaches in the DPT program. Dr. Galantino received her BS degree from the University of Pittsburgh and her MS from Texas Woman’s University while working at MD Anderson University Cancer System. She earned her PhD from Temple University and post-doc from the University of Pennsylvania.
The focus of her teaching, research and advocacy is to advance chronic disease rehabilitation, with a special emphasis on HIV rehabilitation and integrative oncology. Her goal is to assure interprofessional translational research for community engagement for all individuals living with chronic illness.
Through her Fulbright Specialist Award, she is a visiting professor in South Africa at the University of Witwatersrand. She is a research committee member in the Academy of Oncologic Physical Therapy, serves on the national Professional Advisory Board of Cancer Support Community and was the APTA representative for the Commission on Cancer over the last six year. She brings passion for interprofessional and community engagement through her teaching, research and clinical practice.
Dr. Nicole L. Stout is a research assistant professor in the School of Medicine, Department of Hematology/Oncology at West Virginia University Cancer Institute and with the School of Public Health, Department of Health Policy, Management and Leadership. She also serves as the Associate Director of the WVU Cancer Institute’s Survivorship Program where she coordinates the survivorship research agenda and supportive care infrastructure development between the cancer center and community.
Dr. Stout’s research focuses on the implementation of prospective, risk stratified functional assessment and symptom management strategies in cancer care delivery and studying community outreach and engagement strategies with rural primary care providers to enable community-based survivorship care. Dr. Stout is the co-chair of the Alliance Clinical Trials Network, Rural Health Working Group, a steering committee member with the Appalachian Community Cancer Alliance, and serves on the board of directors for the West Virginia Oncology Society.
Dr. Stout is an internationally recognized expert and leader in the field of cancer rehabilitation and survivorship care. Her work and research have been foundational to developing the prospective surveillance model for morbidity management in cancer care. She has given over 300 lectures nationally and internationally, authored and co-authored over 90 peer-review and invited publications, several book chapters, and is the co-author of the book 100 Questions and Answers about Lymphedema. She has led expert consensus initiatives through the American Cancer Society, the World Health Organization, the National Institutes of Health and has served as a content expert in cancer survivorship and rehabilitation for media outlets across the US.
She received her Bachelor of Science degree from Slippery Rock University in Pennsylvania, a Master of Physical Therapy degree from Chatham University in Pittsburgh, Pennsylvania, and her Doctor of Physical Therapy from MGH Institute of Health Professions in Boston, Massachusetts. She also has a post-graduate certificate in Health Policy from the George Washington University School of Public Health.
National Center for Complementary and Integrative Health
The Cancer Support Community (free counseling, group support, yoga and tai chi classes, nutrition workshops and health coaching)
https://www.cancersupportcommunity.org/
National Comprehensive Cancer Network (great clinical practice guidelines
Society for Integrative Oncology (excellent CPGs for integrative therapies)
I would also added potential for enrollment in the clinical trials postings through Memorial Sloan Kettering and Dana Farber at Harvard
https://www.mskcc.org/cancer-care/diagnosis-treatment/symptom-management/integrative-medicine
https://myzakim.dana-farber.org/
We are conducting a yoga clinical trial now at both institutions and I attach our recruitment flier as well (the PI is Dr. Ting Bao).
https://directory.hsc.wvu.edu/Profile/61668#research
00:00 Dr. Ginger Garner Hi everyone and welcome back. This is Ginger Garner and I am just so over the moon to have two guests with me today. We are sad that the third co-author of the chapter could not be here, but I just want to give a shout out to her when that moment is right. But I want to welcome Dr. Mary Lou Galantino and Dr. Nicole Stout to the podcast today. Welcome guys.
Dr. Mary Lou Galantino/Dr. Nicole Stout: Thank you for having us.
Dr. Ginger Garner: Yeah, I am so glad that we could finally make this work. It feels like it’s taken a long time and it really has. So this is going to be a special podcast. But let me do a little bit of introducing them to you first. Dr. Mary Lou Galantino is a distinguished professor at Stockton University where she coordinates a holistic health minor, important stuff, and teaches in the Doctor of Physical Therapy program.
Dr. Galantino received her BS degree from the University of Pittsburgh, her MS from Texas Women’s University while working at MD Anderson Cancer System. There she earned her PhD from Temple University and a postdoc from the University of Pennsylvania.
The focus of her teaching, research, and advocacy is to advance chronic disease rehab with a special emphasis on HIV rehab and integrative oncology. Her goal is to assure interprofessional translational research for community engagement for all individuals living with chronic illness. And that impacts the majority of Americans today. She has also, through her Fulbright Specialist Award, she’s a visiting professor in South Africa.
So she has a very unique viewpoint there, which I’m very grateful for.
She’s also on the research committee for Academy of Oncologic Physical Therapy, serves on the National Professional Advisory Board of Cancer Support Community, and was the APTA representative for the Commission on Cancer over the last six years. She brings a lot of passion, a lot of wisdom, a lot of knowledge on this topic of talking about people impacted with cancer and what we can do to support and help them today, which is going to be what we are talking about.
I also want to introduce to you Dr. Nicole Stout. She’s a research assistant professor in the School of Medicine and the Department of Hematology and Oncology at West Virginia University, not far from me, at their Cancer Institute and with the School of Public Health, probably one of my favorite topics in the world, Department of Health Policy, Management, and Leadership.
She serves as the associate director of the WVU Cancer Institute Survivorship Program, where she coordinates the survivorship research agenda and supportive care infrastructure development between the cancer center and community. Her focus on research is the implementation of prospective risk stratified functional assessment and symptom management strategies in cancer care delivery and studying community outreach and engagement strategies with rural primary care providers. Really important work to enable community-based survivorship care.
She is also the co-chair of the Alliance Clinical Trials Network, Rural Health Working Group, which is a steering committee member with the Appalachian Community Cancer Alliance, and serves on the board of directors for the West Virginia Oncology Society. She is an internationally recognized expert and leader in the field of cancer rehab and survivorship care.
She’s given tons of lectures, over 300 lectures nationally. I believe Dr. Galantino, over 250. You guys are like rock stars. She has led expert consensus initiatives through the American Cancer Society, the World Health Organization, the National Institutes of Health, and has served as a content expert in cancer survivorship and rehab for media outlets across the US.
Her education, a BS from Slippery Rock University in Pennsylvania, the MPT, her Master of Physical Therapy degree from Chatham University in Pittsburgh, Pennsylvania, and her Doctorate of Physical Therapy from the MGH Institute of Health Professions in Boston. And she has a post-grad certificate in health policy, another personal favorite of mine from George Washington University School of Public Health.
Welcome.
Dr. Mary Lou Galantino: Thank you.
Dr. Nicole Stout: Thank you.
Dr. Ginger Garner: Thank you for being here. I also wanted to acknowledge in their chapter, Dr. Lisa Vanhoos, which she supported and helped contribute to the oncology chapter for Integrative and Lifestyle Medicine in Physical Therapy, which is what we hope to be a very important text with teaching our future PTs how to embrace integrative and lifestyle medicine before they get into practice. Because I think I can speak for all of us that we didn’t get. I did not get that in my training. I went to UNC Chapel Hill. We had to grow up as new PTs learning how to do this. So we’re hoping to change that for the future.
I would love to hear how you were both, where your passion was born for this topic of cancer survivorship and supporting people who have been through and are experiencing cancer.
05:26 Dr. Nicole Stout How did you land with that passion point for you guys? Mary Lou, you tell your story first because mine dovetails and intertwines with yours 20 some years ago. So go.
05:41 Dr. Mary Lou Galantino Well, thank you, Nicole and Ginger. Thank you so much for the kind introduction and for your visionary commitment to firstly these podcasts to get information to our colleagues and consumers. In addition to the books, that’s plural books that you have written to touch the lives of so many. Your lifestyle medicine book is now in Johannesburg at the University of Witzwaters-Wand. It is on the shelf for the faculty. So I want to thank you for really helping me to shape the conversation because it really is the foundation to health and well-being.
So with that said, this journey was never on my radar as a physical therapy student at the University of Pittsburgh. I might have received one lecture on pathology and cancer at best. So I had to really use all the skills when I was asked to be a physical therapist in hospice in Portland, Oregon, actually. Goodness in 1983. And what’s really remarkable is the fact that I actually, it’s an on the job experience. And I think the start of integrative health really quite frankly happened at the end of life for my work in hospice.
And I realized then as I was doing home care that I wasn’t sure who was the patient and who was the clinician in moments of end of life in the early 1980s. And then I knew I needed more education. So that’s why I chose MD Anderson, University of Texas Cancer System, to really do some training in the early 80s in a way that would help to really catapult knowledge, a sense of looking at all different types of cancers, the impact on function, quality of life. And then I was very fortunate to have the opportunity to work with a great team, but then also foray into my HIV work in our Kaposi Sarcoma Clinic.
So I’ve really taken a journey in a way that has, that it’s a calling. There’s no other way around it. It’s a true calling. Ultimately, if we fast forward and I found myself returning to the academy to really learn more about exercise and the immune system specifically, that really had me return for both my master’s and my PhD and my postdoc, because my postdoc was an NIH fellowship in integrative medicine. And so I was really fortunate to learn quite a bit of epidemiologic studies and research and be able to then ultimately round it out with my postdoc.
However, on a personal note, it’s really a humbling place to be when we become a patient in our own system. And when I was pregnant with my son, I found my breast tumor, which was actually a misdiagnosis because we navigated a delivery, navigated an immediate visit by the breast surgeon, and it could not be detected on ultrasound nor mammography. And therein lies the joy of clinical trials.
And I want to put that plea out there because as someone who is determined to find this tumor and the breast surgeon did not want to biopsy, I knew there was something there. I enrolled myself in a clinical trial, not on MAMO, not on ultrasound, but there was the 2.3 centimeter tumor, ER positive pathology report. And I had a one and three year old and a great physical therapist, Nicole Stout, who was really the key person who walked me through right by my side. And it doesn’t matter how much knowledge you know, we become the patient in a system that you’ve served valiantly and in a very committed way. You really needed to turn to the people that would support you. And therein lies my journey and the connection with Nicole as well as my personal physical therapist.
So, you know, this is a big, I am grateful. It’s, you know, 20 plus years later. And I’m very, very thankful to have the personal experience. My husband’s a head and neck cancer survivor. So I have the view and the kaleidoscope of being, you know, a clinician, researcher, cancer survivor and co-survivor. And may my children be spared. So on a wing and a prayer, I will tell you that I am here and really honored to share that kaleidoscope of perspective. So I’ll have Nicole take it from there. Thank you.
10:55 Dr. Ginger Garner Wow. I did not. I did not know about that connection. So that just gave me chills and made my heart like get a little full of listening to that. Wow. You’re right. What a segue.
11:06 Dr. Nicole Stout So, Nicole, tell me your story. I am visibly emotional because that was really a moment in time when you pause and you say, here’s my mentor dealing who’s guided me in learning in this incredible area of oncology with a cancer diagnosis and turning to me and saying, what do you think I should do? And I’m saying, you’re the expert. I’m new to this.
So much like Mary Lou, in my undergraduate and my undergraduate is more of a public health focused degree from Slippery Rock and Community Health. And I went to school thinking that it was all about sports medicine as a high school and college athlete. And boy, did I find ortho to be boring. Sorry, folks. That was just not my bag. And I still when I came out of school, I had the very, very, very fortunate experience of taking my first job as a newer graduate at Penn University of Penn. HOP was the it still is a preeminent cancer institute in the United States. And what a great place to start as a new clinician in a pretty intense environment.
I met this phenomenal clinician who identified in me that I had great manual skills. You know, when you’re in school, you don’t know what you’re learning compared to other curricula. And I just thought that learning things like strain, counter strain and muscle energy was normal in P.T. curricula. And it’s not. And but like Mary Lou, I really had very little exposure to oncology.
So coming out into Penn, starting work in the outpatient, I started in an inpatient setting for about a year and then moved into outpatient. And I had this phenomenal mentor who who identified my excellent hands, I guess. And what that did was it led me to working with individuals with chronic pain. And a lot of that was cancer. And when we then had the very fortunate experience in the late 90s of having a physician come to Penn, who was a physical medicine and rehabilitation specialist, she had done her fellowship at Memorial Sloan Kettering and she was coming to start a cancer rehabilitation program. And there was it was interesting. There wasn’t a lot of interest in our department for people to go and get training.
We started with lymphedema training and a few of us went for that. There was actually some pushback from some of the folks on our staff then. Again, this was the late 90s. We didn’t have the survival rates that we do today. We didn’t think about survivorship and the benefits of rehabilitation like we do today. So Andrea Sheffield came in and really was she was the physician colleague of ours.
It was a game changer. It was eye opening to the rehab department, rehab medicine. It was eye opening to the Cancer Institute. And by virtue of her force of nature that she is, she’s an exemplary clinician and researcher. But really, I think most of all, what she did at that time was she got the physicians in the Cancer Institute to recognize the benefit of rehabilitation, which still remains a huge gap in in the medical paradigm of oncology today.
Not only did they recognize it and start sending patients for rehabilitation, they were on board early. So we started getting patients almost immediately postoperatively from the neck dissection procedures and the mastectomies. So I really felt like I had an opportunity at that time working with the development of that program to to see things that no one else was seeing in from a cancer rehab perspective. Many places around the country had not, outside of Memorial Sloan and MD Anderson, places just didn’t have this type of program.
And by virtue of that, I was able to start a couple of research protocols looking at what happens when we use rehab early in the intervention as an intervention in the continuum. And we had a growing program. I got to see a lot of varied and different types of cancers. And it really it was an amazing experience.
And then I presented some of my research at a CSM conference. And this man and this woman come barging up to the stage. It happened to be Charles McGarvey, who again is another icon in oncology rehabilitation and Cindy Falzer, both of them. Just amazing. And they said, you need to come work with us. They were trying to get a protocol off the ground at NIH in a collaboration with the Naval Hospital in Bethesda. And the protocol was prospective surveillance.
And so I knew nothing about Washington, D.C., knew no one. I just knew it was a lot of traffic. And I picked up and I left Penn and I moved to D.C. to take on work with the two of them and then eventually ascend to be in the P.I. of those studies.
And, you know, along the way, I came to realize sort of how specialized it was, what I was doing. I was just seeing things. I always say, Ginger, I’m like an expert by default because there just weren’t a lot of people doing what we were doing to the degree at which we were doing it and patients we were seeing at the time. And so along the way, my fabulous mentor says to me, Nicole, I think you should be the next president of the oncology section of APTA. And I’m this newer-ish therapist. I’ve probably been out of school five, six years. And I’m like, Mary Lou, that’s so nice of you. She’s just being nice to me. Let me just help you here.
So then it puts my name on the ballot. This is when we used to get the ballots in the mail and it shows up. And I’m the only one on the ballot for one. There’s my name. And immediately I was like, I have sucker written on my forehead. She just she got me. So I took over as the president of the oncology section and I did two terms there from 2003 until 2008. And really, it was a transformative time in oncology, rehabilitation and oncology to begin with.
In 2004, the Institute of Medicine report came out, Lost in Transition, and it talked about this huge gap. We do a great job of treating people with we do a great job of treating the cancer and we do a terrible, terrible job of treating the person as they go through the cancer treatment. And then when they’re done, they’re really lost. We transition and we say, you’re a survivor. Good for you. And patients just feel lost. What’s next? I still have pain. I still have fatigue. I still have neuropathy. I’m still falling. I still have fear, anxiety. I can’t sleep. All of those issues.
So that really started the survivorship movement. And so that dovetailed really with the time that I was coming along with the prospective surveillance research, some of the leadership roles that I took on. And I have to say the the prospective surveillance research was a game changer. I mean, I’m honored to this day that Cindy and Charlie, you know, coaxed me and recruited me to come work with them. But what they did also was mentored me and then gave me the reins. And I took those studies over as a PI.
And it really helped me develop my research chops, but also that clinical engagement and experience. And I developed as a leader along with that through my APTA time. Served on the board of directors, the big board after that, and have done, as you said, many special projects.
I think for me, the biggest thing has been just watching this transformation in our field, not just in oncology rehab, but oncology, the bigger cancer care continuum and treatment of oncology of cancer. And really seeing how much attention has been focused on the needs of survivor, but yet of survivors, but yet how far we still lag behind and languish in implementing models of care, implementing interventions that will help individuals best cope with their cancer treatment and side effects.
And I think that the compelling thing for me has always been, I sort of feel like PT’s the underdog, right? You walk into the tumor board and they’re like, physical therapy, what are you doing here? Leave my patient on a treadmill, they don’t need to lift weights. I’m like, haha, you’re wrong. Maybe they do, but not in every instance. And I think that’s the beauty of what we bring as rehab professionals, the ability to really assess, screen, assess what is the impairment. We have a large toolbox. Sometimes it is resistive exercise or aerobic conditioning, but sometimes it’s therapeutic activity, like, you know, balance training and very nuanced types of interventions.
And to think about that spectrum being underutilized, it was just heartbreaking to me because I always knew and I still know we can do better. And that’s really what drives me now is not just the rehab, but thinking about the bigger aspect of survivorship, because prospective surveillance is prospectively assessing problems that people have. Physical, cognitive, emotional, financial, family support, it should be all of it. That’s the survivorship continuum. We should be walking alongside of patients. And that’s sort of the trajectory that I’ve taken my work and my career and my research.
20:28 Dr. Ginger Garner Yeah. And that’s why I wanted to talk to you guys today because I mean, your chapter that you wrote on oncology in Integrative and Lifestyle Medicine speaks to all those aspects of, to throw out jargon for, because we’ve talked about a lot of jargon already, but biopsychosocial is another kind of jargony term that health care providers and researchers can throw out.
But that chapter speaks to what it means. It speaks to what you were mentioning, Nicole, of is it sleep hygiene that we need to be talking about? Is it basic hydration and nutritional needs? Is it more of the psychosocial aspect of relationships and their support system? Do they live in a food desert? Can they even safely exercise outside at all? Can they access green space? And so from your perspective, I think one of my first questions is on the one hand, there’s these interventions. And I think I want to talk about that second, like the integrative and lifestyle interventions that people should know about. What should they be getting? What care do we want them to access? Right.
And then on the front end, how can we better speak to the conditions that really impact women who are cancer survivors? We spoke a little bit about before we pressed the record button, we talked about language and bias and things like that. Can we talk a little bit about how we can de-stigmatize things, especially for women, the women’s health care experience, before then we go and talk a little bit about treatment?
22:11 Dr. Nicole Stout Sure. And I think I brought that up in our sort of pre-call prep. I feel as though we do have to think hard about the language that we use when we communicate across the board. And I go back to something that I heard from a nurse, oncology nurse, Lily Shockney. She’s an amazing oncology nurse from Johns Hopkins. And she says this, and it’s so true. We see thousands of patients and they see one of us.
And we always have to keep that in the forefront of our minds when we’re communicating, because it’s so easy for us to think we get into the diatribe of here’s your diagnosis. This is what we see. This is how the treatments that you’ll get. Here’s the side effects, right? Like that pharmaceutical commercial that we see on television where they sort of rattle all of those things off. And that becomes how we approach care.
And we have to remember that the patient is hearing those words for the first time. When they’re sitting in front of us. And so we’ve got to think about how to contextualize it so that they not only understand, but so they can really feel like they can absorb it and feel as though they’re being heard. And allowing them space to ask the questions. I do think we need to think deeply about communication.
I think we do this fairly well in rehabilitation, especially in PT, right? Our job is to get people to do something that’s probably painful, that may not feel very good, may not make them feel very good in the next day or so, but help them to realize that it’s going to help them in the long run. So I feel like we have good skills there. But we’ve got to understand that sometimes the language can be stigmatizing. And especially to women.
I was just sharing with you all, I was reading a thread on Twitter about stigmatizing language around hormonal therapies and the different way that we talk about breast cancer hormonal treatments and prostate cancer hormonal treatments, right? Men get androgen deprivation, right? Poor them or depriving them of androgen and the side effects that they have. And then with women, we just talk about estrogen modulation.
And it’s very, it doesn’t really carry with it the same sense that they are, they’re being deprived of a hormone or hormones that are incredibly important to how they feel, how they function. And just that sort of stigma, that language can be, it’s just our own implicit way of approaching the conversation, but we should step back and be able to think more deeply about how we can understand where the patient’s coming from and meet them where they’re at.
24:49 Dr. Ginger Garner: Yeah. The language that can be used to describe a range of women’s health issues is often marginalizing. It’s definitely not validating and sometimes it’s even gaslighting. It’s a range, but oftentimes it is assigned to things that women are going to experience. And you also mentioned gendered terms and a kind of stigma associated with obesity as well.
So not limited to the oncology sphere and the cancer survivorship that we’re talking about, much more than that too. And I don’t know, we can’t immediately change that. We can speak to other clinicians, I think in the therapy world, we’re very sensitive to it. But if you’re listening to this and you are going through an experience with cancer, you also have a right to kind of hear from the experts what language you should be hearing. What does compassionate, inclusive, non-marginalizing language sound like?
25:55 Dr. Nicole Stout: We’ve had patients say to us, I had a woman say, I can’t sleep at night before my doctor’s appointment because I know the first thing they’re going to do is ask me to get on the scale when I walk in there. And that’s devastating to me because I know I’ve gained weight through breast cancer treatment. I am not in the body that I used to be in. And it’s heartbreaking for me to step on that scale and then to know that they’re going to tell me I need to lose weight, I need to exercise. And she said, do you think I’m not trying? And that message right there, it isn’t words, it’s the act and the process of bringing the patient in, having them step on the scale, because that’s the box that we have to check.
Mary Lou, you have a very different perspective on this, just from the global society and global perspective. I think that’s on women’s space and language.
26:42 Dr. Mary Lou Galantino: Well, I think it’s thank you for pointing that out. And just coming off of a Fulbright in South Africa, working with women and empowering women to speak for their rights was certainly one of the major considerations in South Africa, specifically rural South Africa. And I saw many young stage three and four cervical cancer survivors, many of whom did not have access. So the issue of access, social determinants of health, all of those considerations certainly weren’t afforded to the many young women that I interacted with, not to mention their autonomy and speaking the truth around their particular needs in sex and sexuality and intimacy.
So, you know, such and for me, you know, I have all the S’s, you know, sex and sleep are activities of daily living that I often ask regularly of all of my patients. And they’re kind of surprised by the boldness. But these are where major changes in intimacy come into play. And no one’s asking the question.
You know, sometimes I think we’re asking more about sleep now a bit more, but certainly these social determinants of health and ethnic racial gender related factors are so, so very important. And I think what is also relevant is the voice of the establishment.
Nicole really pointed this out. It is the environment that we bring individuals into. When I did home care, I was on sacred ground in an individual’s home, very different than when patients come to us. And I will also highlight language is imperative in policymaking because Nicole and I were very instrumental in crafting language for the Commission on Cancer.
We could have a voice, but if the voice isn’t landing on policy change, that oncologists, surgeons, radiation oncologists and the like are not even referring patients into our care. They can’t even begin to know what to ask for. So with all of the evidence that is there, we crafted a language 4.6 in the standards of practice now for all accredited cancer centers across the United States. And let me tell you, it took a village to make it happen.
It was our physiatrist colleague, our PT Academy, that really took a team to provide the evidence because as Nicole shared earlier, physical therapy around the tumor board table. Well, yes, we need to be there early and regularly because now we’re a standard. So by having that as policy, there must be a mechanism for referral for targeted assessment of function.
It’s a beginning. We got our foot in the door with a place in the policy, a standard that must be checked off for accredited cancer centers. And that is actually, so we’re talking both for empowerment of asking for what we need, but also that the policy is in place to expedite the care.
30:27 Dr. Ginger Garner: And that’s a huge, huge step. And in women’s healthcare, there’s kind of simultaneous ships moving through the night. It feels like quite slowly to arrive at a destination that we’re doing the same thing in pelvic health right now, but we have to do it legislatively in Congress to be able to mandate that access to care. So I think that if you’re listening as a therapist and you wonder why is public health and policy important, well, because you can’t practice without it. You won’t have anyone to see without it.
And then from a patient perspective, I often talk to my patients about that importance of being involved in their community and, or maybe it comes down to a question of voting. I have a little sticker on my laptop that just says, you should vote too. Everybody go vote. Everybody be involved because it’s that policy that will create access and sustainability for what we’re doing. And that just can’t be underestimated.
So that’s amazing that you were able to get that done. Just knowing how hard it’s going to be for us to get this established in pelvic health as well, because there are no standards of care for perinatal, you know, the perinatal population, prenatal and postpartum.
31:49 Dr. Mary Lou Galantino Do add Ginger, since I’m also a pelvic health therapist as well, do add all of the cancer gynecologic needs for pelvic health as well. So I just wanted to insert that. And Nicole’s very well established in that as well. So I think it is important to address those areas and to the degree to which we can help in that policymaking. And I want to, you know, make a plea to our listeners here. However, that advocacy can come to fruition and how we can also help to drive that articulation of the verbiage that’s acceptable within the policy makers and actually, you know, showing up to our legislators to make the difference.
That I think is essential, because without these changes from a policy perspective and a reimbursement aspect, can we see access, because we know the financial toxicity in cancer is huge. And that is one of the stressors. And I think, you know, Nicole’s patient example of I have to show up at the physician well perhaps, you know, she does have he or she does have healthcare coverage. But you know, you’re not talking to your physician about your spiritual health, your sexuality necessarily, or financial toxicity or depression or anxiety, even they do the quick screening, there really needs to be that distress inventory that then leads to psychologically informed physical therapy as a possibility.
So I think, since we as rehabilitation specialists really can see from a broader perspective and can ask some of these targeted questions regarding quality of life, this is really where we are well poised to deliver optimal care at with a prospective surveillance focus because 60% I’m going to say it again, 60% of cancer survivors live with functional morbidities that impact on activities of daily living and quality of life.
34:05 Dr. Nicole Stout: So that they have at least one at least one impairment that prevents them from getting through their daily activities.
Yeah, I just want to comment on the idea of access and you hear the word thrown around a lot and you have insurance and so now you get payment for the service and so patients have access and I bring a very different perspective in a rural area. Because you can have all the insurance you want but you do not in many instances have access based on your zip code and the county that you live in and those are the number one determinants of how well you will get through your cancer treatment, live the rest of your life, and function.
So it’s really been wonderful for me being in West Virginia for over four years now at WVU growing up in the Pittsburgh area. I feel like I’m not far from home but to really really absorb and to focus on the social determinants and their influence. Place matters and as we know it trumps almost any other behavior health behavior health comorbidity.
Where we live matters and we’ve just started to scratch the surface in talking about this in rehabilitation and you know kudos to some of my colleagues at MD Anderson who invited me to with them talk about a framework for social determinants assessment and cancer rehabilitation because when we talk about those patients as you just said Mary Lou those individuals who have 60% of them have some level of impairment of those about 40% suffer some type of disability and now we’re really talking about place mattering even more. And so Dr. Ekta Gupta led the manuscript that we published earlier this year I was the senior author on that it’s an oncology issues and it’s a really nice descriptive framework for how we should be assessing social determinants based on the CDC social determinants definition framework but how we can apply that to cancer rehabilitation.
You know, as you mentioned earlier Ginger, does a patient live in a food desert do they have a lack of specialty providers can they even get screening, right? Cervical cancer screening, can they even get it at their primary care facility, right? These are screening tests that have been around for decades. We know that they contribute to early diagnosis of cancers. We know that they save lives and change outcomes.
Can they even get them in their neighborhood? One of the things I’ve learned is we are not going to increase provider density in rural areas like it is in urban areas. It isn’t going to happen. So we really have to examine what are the disparities? How do we manage the disparities and how do we put patients into better contact with those expert providers because of the disparity.
Is the disparity, is it education level? Is it health literacy? Is it poverty? Is it income? Is it the environment and the surroundings that you live in in your community? And whether you are in Baltimore, Detroit, Los Angeles or Weston, West Virginia there are disparities. They exist and they are significant. So it really needs, I think what our focus when we talk about access we should be looking at what are the disparities that these individuals experience in accessing care.
How do we alleviate the disparity until we eliminate those disparities all of the telemedicine… Telemedicine doesn’t work so well in rural West Virginia. We do not have broadband access. We do not have access to internet services many people don’t have internet in their homes. They don’t have the equipment to do a telehealth visit. I could go on and on about that but we’ve got to really look at the disparities.
How do we collapse and close the disparity that individuals experience regardless of where they live, what their race, ethnicity, gender, sexual identity, there are disparities everywhere. That to me is sort of the core focus of what I need to do in rehabilitation and providing. To go back to our topic, the lifestyle medicine cancer survivorship is lifestyle medicine. It is how do we get individuals through and beyond treatment and that’s exercise, that’s diet, that’s sleep, that’s cognitive behaviors, that’s you know meditation, it’s it’s whatever the patient needs to continue to function in addition to and alongside their medical intervention. So I feel like that chapter that we were able to contribute to really gets at those you know those core issues.
38:51 Dr. Ginger Garner: And I think that those pillars are really important to point out when we’re talking about what treatment should look like. And you could extrapolate this to many populations. If you’re talking about prenatal postpartum, if you’re talking about pediatrics or geriatrics, it’s not just, you know, oncology alone because that’s what the whole book covers. It’s across the lifespan. We need these pillars across the lifespan of the things that Nicole just mentioned and I’ll just say them again for the listeners.
If you’re a practitioner you need to be able to talk about these things and if you’re a patient and a recipient a consumer of health care as we all are then this is your right to have access to someone talking to you about this. It’s sleep how are you sleeping? Someone should care. Someone should ask. Physical activity? Which doesn’t necessarily mean exercise. Physical activity is accumulated movement throughout the day. I was able to write the chapter on the book in that and a lot of times I think we saddle people with an expectation of physical exercise, when lots of people have aversion to that for different reasons. So it can look like a lot of different things. Our relational status and our support system? How we look at nutrition and what we’re eating every day. We definitely are what we eat. How’s our hydration? How are we getting hydration?
And what else did I miss other than environmental influences which in oncology have that’s a whole other podcast that we could talk about or the environmental influences on whether or not someone goes on to you know develop cancer. So all of those things are what you have a right to as a patient to access and if you’re not talking about it as a practitioner and you’re working in oncology then there’s a chapter out there you should be reading.
40:48 Dr. Mary Lou Galantino: And if I may add ginger I love that you encapsulated all of those factors that lead to to shifts in one’s perception of their well-being to engage in lifestyle medicine at any level along the lifespan. I would also probably add community resources as one of those very key factors. And Nicole as you were describing, if I could just tell you I could have been in West Virginia or South Africa and describe similarly my populations as well in the three rural provinces that we visited.
Because the other issue is transportation. You know just getting to us and that’s the reason why most of the young women and women throughout the lifespan were diagnosed in late stages because of access. However, cancer is one of those very few diseases that actually has a support community across the United States and for listeners who are cancer survivors or co-survivors, the cancer support community is one such entity.
In some areas it’s still called Gilda’s Club. Then they’ve merged to really create an amazing community-based service that is focused on learning how to cook healthily, learning how to navigate stress/anxiety/depression in support groups, art therapy for children. Like my children underwent when we were going through our cancers. We had a place to go even beyond the medical establishment and I want to say that that is so very important.
And for our colleagues that are listening, so many times if I hear myself say well perhaps you know would you like to see a therapist or would you like to find a community, will the YMCA receive you? In terms of would you be amenable to that? Like really looking at these behavioral change aspects using whether it’s a trans theoretical model, the social cognitive module, theory plan behavior all of those we know. But the bottom line is: are we as practitioners giving a warm hand off?
Let me make the call for you.
Would you like it?
And I find that we can recommend but unless that true transition into the community takes place I’m really concerned that due to financial toxicity individuals may not be able to afford it. But certainly all of the free services that the cancer support community provides would be certainly ideal.
And I actually serve on the national professional advisory board and I just finished with a colleague who got her PhD at the University of Delaware looking at health coaching in cancer survivorship. And that is now being looked at to be adopted across many cancer support communities. It would be free for all participants for this behavior change strategy, improvement in nutrition, physical activity, and then free yoga and tai chi classes. So I just think it’s so important that as we advocate for our patients and for those who wish to engage at the community level, being able to reach out to cancer support community is just one of the many wonderful support opportunities for service.
44:27 Dr. Ginger Garner: I think that’s probably the most important aspect because you can’t really implement any changes at all if there’s not a support system, if they can’t reach out into the community, if they they don’t have you know the basic steps to get there and also the mindset.
The growth mindset to know that they can and that they are capable of making a shift in the way they you know set up their situation to sleep at night or how they do their hydration during the day. So I think that that often is a common thread of coming back to if we’re not connecting and really helping them plugin then the most well laid out rehab plan is not going to do anything at all.
45:11 Dr. Nicole Stout: And I add to that I think we have to think beyond just rehab. We are a service line and comprised of many different services, right? Occupational, physical, speech therapy. There are exceptional exercise professionals in our communities. There are exceptional dieticians in our communities, social workers, and community health workers.
We have to be able and willing to expand the sphere of people who can and should be engaging with our patients we just did a statewide needs assessment focusing on cancer survivors here in the state of West Virginia and looking at needs across five domains. We also do qualitative interviews and what we heard across the surveys and the interviews were the needs for support in their communities. We call it care close to home.
We’ve got to be able to give them care close to home. What we heard were things like well the dietician at the cancer center wanted to see me for all these follow-up visits but I can’t drive an hour and a half one way to go see her and then she wants to do a telemedicine visit. Well you know my data plan is only 100 minutes a month and I can’t use minutes on that because I have other priorities.
So we really have to think about where in our communities can we find exercise professionals, senior centers, and community health centers. Where we can work with those providers or professionals, train them in the nuances and the needs of cancer survivors so that they can offer those services close to home.
When we did an environmental scan on following that we found over 200 exercise facilities and rehabilitation facilities around the state of west virginia. Do you know how many of them offer cancer rehabilitation or cancer exercise service? We had 11. 11 around the state that offered that service and so the capacity is a kind of on us to build that.
I think we’ve I have a bias of course working in oncology my entire career I feel as though we’ve taught generations of rehabilitation professionals cancer in the negative. We’ve taught them all of the contraindications to exercise and all of the contraindications to modalities and all of the safety red flags. But what we haven’t done is we haven’t taught them how to take their knowledge as a rehab provider and apply it in the context of oncology. And that’s where we we fill that gap.
The rehabilitation professional who’s got a free-standing outpatient facility in a small town says I can’t see this patient for the prehab program that you sent them with because they have cancer and it’s a contraindication for me to exercise with them. So we’ve got we have a lot of work to do I think in educating across the profession that yes these lifestyle medicine interventions these rehabilitation interventions all are applicable to the oncology population.
How do we teach them to apply the good knowledge and skills that they have in the context of cancer to help those individuals across the lifespan? Because the other fact that we haven’t talked about yet is upwards of 70 percent of people who are diagnosed with cancer are going to survive and live the remainder of their lifespan disease-free but they’re going to do so with the morbidity that Mary Lou referenced earlier.
So survivorship is an exploding population good for the medical community. Good for us, right? Doing such a good job of early detection, treatment of cancers. The morbidity that those individuals face lifelong, however, we need to do a bit of a better job elevating our knowledge base in our profession to be able to help those individuals. And that’s rehabilitation, therapeutic exercise, and all of the pillars of lifestyle medicine because that’s really what these folks need throughout their remainder of the lifespan.
And I love the coaching concept ML, that is just and I feel like sometimes that’s just what people need they need, just a almost a nudge. They they need someone to give them license to say it’s okay if you want to go to the gym, it’s okay if you want to try this tai chi class, or it’s okay if you want to do yoga.
Sometimes patients say they get nebulous recommendations from their physicians. And when the doctor says well I don’t really know or yeah you could do that but… That’s disheartening to them. So giving them uh getting information from your physician that is half-baked or you know quasi-developed and and we hear a lot of that. You know, yeah you could probably exercise but don’t overdo it. Well, what does that mean, right?
Put the patient in contact with someone who can coach them through that. And it doesn’t necessarily have to be the rehabilitation intervention of three times a week. It can be this coaching dialogue just like we’re having here, once a month or once every couple of weeks. Use apps to communicate, use calendar reminders, you know to to help them create strategies in their life to just lead them to those lifestyle interventions.
50:28 Dr. Ginger Garner Yeah there are so many wonderful things we presented on CSM last year on using apps and the technology of apps and how it’s improving just people’s ability to feel empowered instead of afraid. And I think that’s kind of a really good maybe finishing point is to emphasize that if you’re encountering that maybe a little bit of half-baked advice, Nicole just like you said, where it’s like well you could but… Then that’s probably a red flag the individual’s not actually speaking from the evidence base.
And what is the evidence base, because that’s another jargony term that we throw around a lot. Are they speaking on what the latest evidence is saying about cancer and exercise, cancer and movement, cancer and mindfulness, participating in yoga and tai chi and whatever that is.
So if we could send a message I think it would be to be one of empowerment instead of one of being afraid of moving, afraid of experiencing, afraid of getting out there. Because there are so many practitioners that can help you do just that. So less fear more empowerment
51:42 Dr. Nicole Stout: I think sometimes I think sometimes that that nebulous or fuzzy recommendation comes from a place of not knowing. I don’t know that it’s malicious on many of our colleagues and physicians part. They just don’t know what are the indications.
Many of our physician colleagues really have never had the degree of education in biomechanics, in exercise physiology, that many of us have had. So they don’t know how to apply it in context and so well yeah you can exercise but don’t overdo it. What does that mean and I think that it comes from a place of just not knowing how to prescribe the way that we know how to prescribe.
Our physicians know pharmacokinetics and pharmacodynamics and they can prescribe those medications because that’s the core and what they know. Exercise, nutrition is not the core. So this is where widen the sphere, right? Bring everyone around in this multidisciplinary or multi-specialty approach to managing patients more proactively
52:41 Dr. Mary Lou Galantino: And I think your point Nicole I think what’s really important is also seeing where our patients, our clients get their information. I’m now involved in an NIH clinical trial looking at yoga for neuropathy. Patients are hesitant to exercise because of the pain and their balance dysfunction. The National Center for Complementary and Alternative Medicine which is now The National Center for Complementary and Integrative Health is a great website for those that are listening.
I want to make sure that given our lifestyle conversation today with that focus that patients and practitioners are using evidence based websites. I often will ask patients where did you get that information? Gingko Biloba: you’re a little low in your mood, how did you decide that? But there’s a drug-herb interactions that we need to apprise when we do our intake and so I just wanted to assure that when individuals are looking on the web that they are exploring evidence-based websites that have credibility, that give answers to many of the questions. If they haven’t been answered by our cancer colleagues, as well, because they will search and search and search and we want to be able to provide apt, appropriate, timely, and evidence-based interventions.
54:13 Dr. Nicole Stout And that’s the good news there, Mary Lou. The evidence base around some of those integrative therapies has increased exponentially and in fact there is a society for integrative oncology and many of their guidelines, there’s guidelines for anxiety, for sleep, and for depression, that I would advise. That’s a great resource to look for also recently the national comprehensive cancer network which is NCCN is kind of our gorilla when it comes to producing guidelines and their survivorship guideline is exceptional. And they just recently added sleep assessment as a part of their 2023 guidelines. So I would encourage individuals out there listening to this, yes you know there are many places you can go to find resources.
55:13 Dr. Ginger Garner: So what we’ll try to do with that which is what we typically try to do and it’s a good time to mention it is putting those links and resources in the show notes. So that people can access those because it’s hard to sometimes listen, maybe you’re out for a walk, or you’re exercising, or you’re listening to this in your car. So we’ll make sure you can go back to the show notes so you can click on those resources because that’s a lot of where our shift from can I do this to yes I can do this comes from is just accessing that good information and you guys have been a wealth of good information today.
We could talk about this for so much longer and and I feel like we’re still cutting it short now but with the good resources that they have, which they’ve gotten a snapshot. You’ve gotten a snapshot of what care should look like, what we would like for it to look like in the future, and a couple of red flags along the way, as well. I think that you know we’ve set listeners up to whether you’re a practitioner or a patient to be in a good situation to source these resources and and come away feeling much better about what you’re doing.
So I do have a couple of rapid-fire questions that I’d love to finish up with. One of the questions I always have is what book are you currently reading now? If it’s a nerdy science book you can share that but is it fun? Is there a fun one that you’re reading?
56:48 Dr. Mary Lou Galantino I have on my I’m actually listening to a Malcolm Gladwell his latest text. I love Malcolm Gladwell. So, I just listened to a podcast by him and have that on the shelf.
57:01 Dr. Ginger Garner: So is that the his one about normalcy? The normalcy? The Myth of Normal is that it?
57:07 Dr. Mary Lou Galantino: Yeah the myth of normal
57:12 Dr. Nicole Stout: So summer is usually my fun reading time. I don’t go to my serious stuff until the fall and winter. So I’m actually reading a book about Anna Wintour. Who is the yes, it’s fabulous! It’s not an autobiography but it is a biography and if you don’t know who she is, she has been the editor-in-chief of Vogue uh since the 1980s late 1980s. And he’s the editor-in-chief and director of Condé Nast which is owns Vogue and many, many, many other fashion and retail magazines. So I am a little bit of a fashionista, but I’m also fascinated by women who ascend and into very, very powerful positions and I love to understand how they got there and that’s what this goes through. It talks about who she is, how she got there. I love her. I think she’s, if you’ve ever seen the Devil Wears Prada, right? That’s a spoof based on her but um she’s really a fascinating woman and a fascinating mind when it came to innovation in the fashion industry. So yeah that’s what I’m reading right now
58:14 Dr. Mary Lou Galantino: All right, I’m for those who don’t know, Nicole wears some serious heels and looks stunning when she runs an executive board meeting. I just needed to share that.
58:26 Dr. Ginger Garner: Now I can’t wait to see you in person next and now I’m gonna have to read that book and I’m working through The Myth of Normal. I usually have I try to work through like a fiction and a non-fiction you know at the same time so that gives y’all some ideas.
All right one more question and that is what is your favorite fail safe thing to do when you need a chill pill?
58:48 Dr. Nicole Stout: Walking outside. Oh my gosh, I have 88 acres. I have trails, I have a garden, I have, I mean walking outside it’s my it’s everything.
59:08 Dr Ginger Garner: Yeah oh wow yeah that sounds like it’s just a magical retreat. You need to retreat at your your farm.
59:14 Dr. Nicole Stout: Silence. The silence is what does it for me and just that peacefulness of being out in nature
59:21 Dr. Ginger Garner: Yeah I can feel that.
59:22 Dr. Mary Lou Galantino: And I love the pinelands. You know I’ve had many opportunities to go to other universities. My university is on the pinelands of southern New Jersey at Stockton. I love nature. I love doing the trails. When in between classes so I might come in for after a sweaty you know run and still teach but you know they’ve got a happier more centered professor stepping in the classroom. And so it is my go-to break, is going for a quick run even if it’s 10-20 minutes.
I also start every day with a meditation so that I could set the tone for the day and then actually do every night a gratitude list where it takes me to a place of knowing that people like you Nicole and you Ginger who touch my life so deeply I get to and be super grateful for touching my life in deep ways.
01:00:18 Dr. Ginger Garner: That was so fantastic.
01:00:26 Dr. Mary Lou Galantino: I said three I know you said one but oh you know that’s my that’s my rhythm of the day.
01:00:35 Dr. Nicole Stout: Yeah I appreciate that. My morning starts with yoga. That’s every morning. Even if it’s just a couple of sun salutations or it’s a whole hour long practice but that’s every morning so um but yeah when I’m really when I really need that hoof walk away it’s go and walk outside.
01:00:44 Dr. Ginger Garner Yeah I completely completely agree with that I think my failsafe go-to is music but it could be in nature, it could be with yoga, you know um but it’s music. It’s so healing and that’s a whole other science for oncology. Music, you know, the therapeutic aspects of that too. But you know what for the listener, that’s a lot of the lifestyle medicine, like that’s it. That’s lifestyle medicine. So go out and get some lifestyle medicine, some integrative medicine and feel well.
And thank you from the bottom of my heart for the work that you’re doing. It is sacred work. 250% sacred work. So thank you. It’s changing people’s lives. And thanks for taking the time out of your busy schedules to talk to us today. So thank you.
01:01:36 Dr. Mary Lou Galantino Thank you and Ginger you have the most amazing voice. When you were running for office I remember your Amazing Grace singing. Perhaps you can end us with a few notes. I don’t mean to put you on the spot but I love your voice. I do think it’s a great way to end.
01:01:59 Dr. Ginger Garner Let me see if I can pull it out here. I have not sung in awhile. That means I need some medicine, because I haven’t sung in a while. Alright I’ll move this way a little bit.
01:02:10 Dr. Ginger Garner: Amazing Grace, how sweet the sound that saved a wretch like me. I once was lost, but now I’m found, was blind but now I see.
01:03:07 Dr. Nicole Stout: God it just feels that all the way through me oh my gosh.
01:03:13 Dr. Mary Lou Galantino: Did you get chills, right? It’s just beautiful. So thank you because I adore your voice and it is another modality that brings healing. And that is the gift in so many gifts that you have Ginger. In being able to serve in this highest capacity of making sure that listeners, practitioners, and the world hears your voice. Whether it’s through your books, your podcasts, your trainings, your patient care ,your amazingness and now you’re singing to all of us on this podcast. So thank you.
01:03:51 Dr. Nicole Stout: Thank you for giving us the platform, Ginger. We’re very, very grateful.
01:04:00 Dr. Ginger Garner: Thank you so much. Thank you so much. And when I see you guys again you’re getting bear hugs, huge. Probably in Boston at CSM (combined sections meeting) but um count on it. Yeah, until then a big old namaste from the south, North Carolina. And I will see you guys soon. Thank you from the bottom of my heart.
Dr. Nicole Stout: Thank you!
Dr. Mary Lou Galantino: Thank you so much. Love to all. Take care and bye bye.
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