[Physio Discussed] What does effective cancer rehabilitation look like? with Dr Briana Clifford and Germaine Tan

0:04SPEAKER_02:Today, we're exploring cancer rehabilitation and exercise oncology, and importantly, how we can translate the growing body of evidence into what we actually do in clinical practice. We'll discuss what cancer rehabilitation should encompass and where it fits across the cancer journey, the role of exercise in managing treatment-related symptoms, and what the evidence tells us about recurrence and survival. We'll also explore an important challenge for the profession, how we improve equitable access to exercise and supportive care.

0:34SPEAKER_02:Joining me today are Jermaine Tan and Dr. Bree Clifford. Jermaine is an APA-titled cancer physiotherapist and clinician researcher with more than 15 years of clinical experience. She is currently completing her PhD at La Trobe University and Eastern Health, investigating how the timing of exercise and cancer rehabilitation influences patient and health service outcomes. Germaine is also the national chair of the Australian Physiotherapy Association's Cancer, Palliative Care and Lymphedema Group.

1:03SPEAKER_02:Bree is an accredited exercise physiologist, researcher and senior lecturer at University of New South Wales, Sydney, with more than 10 years of clinical experience supporting people affected by cancer and other complex conditions. Her research focuses on exercise oncology, cancer-related symptoms, and improving access to high-quality exercise services, including the role of exercise in managing fatigue and chemotherapy-induced peripheral neuropathy.

1:29SPEAKER_02:You're going to get a whole lot out of today's episode. I'm Sarah Yule, and this is Physio Disgust. Jermaine and Brie, thank you so much for joining us on the podcast today. Jermaine, let's start by setting the scene. What is cancer rehab and what does the current evidence and clinical landscape tell us about what it should encompass?

1:53SPEAKER_00:Yeah, thanks, Sarah. I'm really glad to be here and just talk about this topic that is really having evidence and research coming through in the last few decades. So cancer rehabilitation essentially is care that should be integrated throughout a person's cancer journey, but often it isn't. And it's usually guided by a whole multidisciplinary team of allied health, nursing, medical health professionals that are equipped in their own clinical areas to diagnose and treat any kind of physical and psychosocial issues or impairments a person with cancer can often present with.

2:34SPEAKER_00:And the goal really is for any person who has a cancer diagnosis is to really optimize their person, their individual function. And if they are having treatment or if they have had treatment, is to really minimize or reduce that symptom burden that our patients often experience, such as fatigue, depression, loss of energy and strength. And the list goes on. And really thinking about optimizing that independence and that quality of life right from start to finish.

3:07SPEAKER_00:And I think just really pointing out that clinicians, often like myself, when I first started, we often kind of thought of cancer rehabilitation as rehab happening at that one point. Often it's really kind of rehabilitation happening across the whole cancer continuum. So, you know, really looking at rehabilitation starting early, such as prehabilitation through to during treatment, and even into the survivorship and really transitioning nicely into kind of that palliative care or end-of-life phase if a person does go into that phase of care.

3:47SPEAKER_00:And I think I really find it helpful as a clinician to think across it as being able to deliver cancer rehabilitation into kind of that four clinical phases. So a framework that I always go back to, I think it was actually published in the 70s, but it's by DEETS. And it's a DEETS framework or classification, and it kind of classifies cancer rehabilitation as preventative or prehabilitation phase, that kind of restorative phase where you're kind of restoring a person's function during treatment or after treatment.

4:23SPEAKER_00:That supportive rehabilitation phase where you're supporting that patient to keep going and maintain their best function as much as they can for as long as they can to live their best life. And right up to the end is palliative rehabilitation, where we know that people with advanced cancer still can exercise and they want to exercise, and we help them to kind of achieve their goals in that rehabilitative kind of way as clinicians. So the landscape over the last few years, I'm sure Brie can talk more about this as well, but there's been so much research to show that exercise is safe and feasible and effective across many cancer patient cohorts.

5:07SPEAKER_00:And so, yeah, it's really exciting to see this happening.

5:11SPEAKER_02:Fantastic. And I think we'll certainly get to the exercise piece shortly. I just wanted to go back the four clinical phases. I call it preventative, restorative, supportive.

5:23SPEAKER_00:Yeah. And the last one was palliative rehabilitation.

5:27SPEAKER_02:That's a really good starting point for us to use as a launch pad, Jermaine. Bree, do you have anything to add to that?

5:34SPEAKER_01:I love the way that Jermaine has laid that out. I think it's a really incredible summary of how the landscape has changed and how important it is that we are thinking about how we can help our patients exercise or improve their function, their psychosocial functioning across the trajectory of care. It's really critical. I suppose that that sort of early access to services is something that in the past people didn't always have. And so that becoming part of the spotlight, how do we help patients access services when they have a diagnosis and make them feel comfortable and safe to exercise across each of those different stages of treatment and care is really critical.

6:14SPEAKER_01:And I think you summarized it really well, Jamaica.

6:16SPEAKER_02:And probably on that three, potentially for a Musk physio who doesn't specifically work in oncology, what aspects of cancer rehab will likely sit within their scope? Just before we move into the practical component of what it actually looks like going uh treating in the clinic?

6:35SPEAKER_01:Within the scope of a musk physio specifically? Yeah. As Jamine has sort of outlined, we're thinking about treatment trajectories. And when we're approaching exercise or exercise rehabilitation for people who have undergone treatment for cancer, we're often thinking about what kinds of symptoms they might be experiencing. And so there are many symptoms and side effects that will impact the musculoskeletal system or have musculoskeletal symptoms and effects.

7:02SPEAKER_01:And so certainly helping people manage the effects of their treatment across the trajectory would definitely fall within the scope of a musculoskeletal physiotherapist, particularly things like post-sergical pre-surgical and post-surgical care. So preparing people for surgery is often about things like increasing aerobic capacity and but also muscular function, joint health and safety prior to having surgery. And then acute recovery is certainly something that would fall within that scope.

7:31SPEAKER_01:But really, long-term maintenance of muscle, bone is incredibly important when we're thinking about many of the treatments. So chemotherapies, hormone therapies all have long-term impacts on muscle and bone. So I think that really there's a role to play across the trajectory of care.

7:49SPEAKER_02:Absolutely. That's a great summary. Let's move into if, and Joanne, I might get you to kick start this one. But if a person with cancer walks through the clinic at any point in their cancer journey, how do we translate the evidence about rehab and exercise into what we actually do with that patient?

8:06SPEAKER_00:When we think about the cancer trajectory, and if I think about any physio who is practicing in their clinical practice, it's really important to note that the cancer trajectory isn't a linear kind of trajectory. It's not like you can take a research protocol about exercise and provide it to your patient. It's not really quite like your ACLs or your sprained ankles in that sense, although I wish it was that simple sometimes. Often we see our patients cycle through back and forth, through diagnosis, tests, different lines of treatments.

8:50SPEAKER_00:For example, a breast cancer patient that walks through your door can be receiving chemotherapy before they start surgery. And if they go into remission, they go on to receive hormone replacement therapy. And like Brianna said, there's all these different side effects that are very specific to the different treatments that they receive. And so I guess as physios or any kind of health professionals who are supporting people with cancer through the journey, you really do need to be actively assessing and picking up and managing these symptoms as they come along at any kind of point in time in relation to what treatment they've been having or whether they've even kind of gone into remission, but then their cancers come back.

9:35SPEAKER_00:And then now they're restarting treatment again. So I think, yeah, exercise kind of health professionals. We have the incredible privilege of spending a lot of time with our patients compared to some of our medical colleagues. So, you know, it's really nice to be able to be in that position to be able to kind of ask the right questions and pick these up, like Brie said, early, um, so that you can get them the right care at the right time as well.

10:03SPEAKER_01:Just to add to that as well, I think that when we're translating the current evidence, because we've got great guidelines now that are both Australian-based and internationally based. So from the American College of Sports, Medicine and Exercise and Sports Science Australia, APC, all have these guidelines that are sort of endorsed by our peak oncology and exercise bodies, which is a really great start. And I think sometimes the difficult part for new grads is when someone comes through the door and they don't necessarily fit the textbook presentation of what they've learned and with like what people will be experiencing and how it matches with what we have in terms of the evidence.

10:43SPEAKER_01:I don't know if that's sort of what you've experienced as well, Jermaine, but I have found in practice and also working with new grads, having an opportunity to have like communication, open lines of communication with other health professionals, like their GP, potentially their oncology professionals, to get up-to-date information about their treatment and discuss, you know, side effects and the impacts of their treatment as it is specific to them is also something that can really help you adapt that prescription or that treatment so that it it sort of bridges the gap between the evidence that we have and what we actually do in clinical practice.

11:19SPEAKER_02:As you've said, it it might be better done with an ongoing discussion with the multidisciplinary team.

11:53SPEAKER_01:Yeah, absolutely. I think having an open communication line with at least their primary care provider, and sometimes that can be really challenging in practice. I think that sometimes patients don't often have good connections with their their whole care team. And sometimes if you're a clinician that's based in the community, it might be difficult to have those open communication pathways with, say, a major hospital who might be providing care. But certainly trying to maintain those communication lines so that you can get the information that you need to guide your practice, I think is really important.

12:27SPEAKER_01:Fantastic. Anything to add there, Jermaine?

12:30SPEAKER_00:Yeah, I think going back to the point Brie made about now we really need to see these amazing guidelines that have been published and see how we can each individually translate that into practice, especially with our new grads. Yeah, Brie has really hit the nail on the head in that sense. Because we really have done research that shows that our physiotherapists in Australia, I think almost 70% reported that they lack confidence to effectively assess and manage someone with cancer.

13:04SPEAKER_00:And that's because of insufficient education or professional development resources or courses being available both in Australia and overseas, but also that kind of lack of support of knowing what to do and what's safe for patients at any given point in time with their treatment. But we do know that the guidelines, like I think there's more than 70 guidelines now relating to exercise and oncology, and consistently it shows that exercise is safe, feasible, and effective across many cancer types.

13:44SPEAKER_00:We had the first kind of level one phase three RCT that was published last year that showed that exercise directly reduces a person's risk of cancer returning by almost 30%, and it reduces the risk of cancer-related death by almost 40%. And this was done in a colorectal cancer population that underwent structured exercise programs for I think three years after they had completed treatment. And so that that message, I think, has now shifted from exercise being a nice to have to exercise being a need to have.

14:27SPEAKER_00:And so right now, I think across Australia and worldwide, we have, I think it's going to be almost like a 50% increase in people living with cancer by the year 2050. So I think that's almost about 25 years' time, isn't it? So not really long to go. And if you think about it, I think we did some research a few years back that showed that only one in 65 patients with cancer can access exercise rehabilitation services in Australia. And so one in 65, that's really little.

15:05SPEAKER_00:And if you compare it to our cardiac and pulmonary rehabilitation programs here in Australia, we have five times the amount of cardiac and pulmonary rehab programs compared to the number of oncology rehab programs. And these gaps are just there. I think we've got the physios who are lacking confidence, but we've also got the need for physios and other exercise health professionals like exercise physiologists to be working together to really improve that access that Bree is talking about to exercise rehab.

15:44SPEAKER_00:And yeah, and I think we really need to say to our physios that even though you like that confidence, you really do have that solid foundations in your basic foundational assessment, clinical reasoning, and treatment skills as a physiotherapist. And with cancer, you have impairments not just in musculoskeletal, but it's across cardio, respiratory, neurological, and lymphedema. And so you can utilize cancer is the one for you. You can utilize all your skills as a physiotherapist, and you can still provide that great kind of generalist care as a physio.

16:28SPEAKER_00:And if you are keen to specialize, you can keep developing and learning to provide that specialist care in cancer physiotherapy as well.

16:37SPEAKER_02:It's a great summary. It's sounding like to summarize for those physios perhaps lacking in confidence, as you've both already alluded to, accessing those guidelines will provide them with a nice found foundation complemented with confidence in our own clinical reasoning. And then that ongoing discussion with the multidisciplinary team, which is obviously going to be a great resource alongside their treatment. Perhaps Brie, I might throw to you on this one.

17:05SPEAKER_02:One of your areas of research has been the role of exercise in managing treatment-related symptoms. What do we currently know about using exercise for symptoms such as cancer-related fatigue and chemo-induced peripheral neuropathy?

17:19SPEAKER_01:I think Jermaine really summarized nicely before that. We have pretty good evidence now to suggest that exercise is safe and it's likely beneficial across the board for most people with a diagnosis of cancer. And there are some symptoms, or at least our treatment and our approach to managing people with cancer should be symptom-specific. So as we have someone that comes through our door, we should be thinking about them as a whole person. They very rarely, as I'm sure we've both experienced, come in with a single problem or issue, but rather they often come in with a whole life experience.

17:53SPEAKER_01:They might have past things that they're holding on to or that they're trying to manage, as well as more current issues related to their cancer and their treatment. And so really having a think about how we could triage those problems and identify which things are most important for us to address, what we can address with broad, perhaps, recommendations and lifestyle advice, and what might need some more specific or tailored, a more tailored approach to exercise prescription, for example.

18:20SPEAKER_01:So I have clinical interests and research interests in cancer-related fatigue and chemotherapy-induced peripheral neuropathy. But they're also two of the most common symptoms that are experienced by people who might have undergone treatment for cancer, particularly things like chemotherapy. We know that potentially up to 90% of people will experience cancer-related fatigue. And that is something that will likely improve significantly over the first year following treatment or completion of treatment.

18:48SPEAKER_01:But there's also a subset of patients that will experience sort of an ongoing post-cancer fatigue that can be quite significant. And so when we're thinking about how to manage cancer-related fatigue with exercise, we really want to be thinking about what point in their cancer trajectory is our patient. So if they're on treatment, we want to help them to manage their symptoms and maintain as much function as possible. And if they've completed treatment, we want to think about how we can help them recover over time and gradually increase their capacity.

19:18SPEAKER_01:And if they are one of those people who is experiencing this really persistent, ongoing post-cancer fatigue, which often can be experienced a little bit like myologic encafylitis or chronic fatigue syndrome, so with those booms and busts and trouble with ongoing function, then we need to take a more, I guess, structured and specific approach to managing that kind of fatigue. So I think that when we're talking about fatigue, really understanding what our patient is experiencing and how to apply our management strategies to that particular scenario.

19:50SPEAKER_01:And then chemotherapy-induced peripheral neuropathy is also a really common condition that likely affects up to 60% of people who undergo neurotoxic chemotherapies. And it's something that can be really persistent and also can have a lot of really functional impacts. And so the research that we've been doing has looked at multimodal exercise for management of chemotherapy juice proofraniopathy or CIPN. And so we know that from what we've seen in the literature so far, that exercise prescription, particularly that exercise that might be balance training and sensory motor training, paired with things like aerobic and resistance exercise, is likely to improve some of the functional symptoms that people experience when they have CIPN.

20:35SPEAKER_01:So that might be a loss of balance or reduced proprioception, troubles with things like emulating, walking, stepping, and an increased risk of falls. Our recent study, which is currently still under review, so it's in the process of being published, has yeah, has excitedly found that a multimodal exercise intervention, which includes resistance exercise, aerobic exercise, and balance training, can actually reduce both clinically measured and patient-reported symptoms of CIPN.

21:03SPEAKER_01:So not only just improving function, but actually that we might be able to reduce those really debilitating symptoms that people might experience when they do have CIPN. So I think that in terms of how we use exercise to manage symptom-specific presentations in our patients, like I said, really important to think about what I am targeting? Is it something that I can approach with a broad approach to exercise? So helping patients to move towards their 150 minutes of moderate intensity aerobic exercise, two strength training sessions.

22:04SPEAKER_01:Or do I need to really take a focused approach to try and manage a particular symptom? Do I need to think about addressing fatigue first, or do I need to then think about addressing false risk, for example?

22:15SPEAKER_02:Just on that, what do we know about dosage and intensity? Obviously, being symptom-specific, every patient is going to be different, but particularly with regards to something like fatigue, where does dosage and intensity come into it? Probably more with reference to that aerobic and resistance training you mentioned.

22:35SPEAKER_01:So when we think about the broad guidelines as a whole, we're really talking about moderate intensity aerobic activity. Now, we know as clinicians, and I guess as people who might know people who have had a diagnosis of cancer and who've been through treatment, that 150 minutes of moderate intensity activity is not achievable. Everybody. And so really the guidelines tell us that more is better than less, avoiding activity more is better than less, generally, and working towards that 150 minutes.

23:03SPEAKER_01:The guidelines are the same for cancer-related fatigue, but we also have some good evidence to suggest that we can modify intensity and dose based on somebody's daily presentation of fatigue. So if someone turns up to the clinic or to their session and they're rating on a vast scale, 1 to 10 vast scale, that they're at an 8 to 9 or 7 to 9 in terms of their fatigue rating, then it would make sense for us to reduce the intensity of their activity and perhaps the total volume.

23:33SPEAKER_01:And when people are rating much lower intensities of fatigue, then we're able to prescribe towards that moderate intensity. In terms of dose response, when it comes to persistent fatigue presentation, we know that with that persistent post-cancer fatigue presentation, that people who are experiencing that can experience what we call post-exertional exacerbation of their symptoms. So too high of an intensity can cause a crash, an exacerbation of their symptoms, which can take a long time to recover from.

24:02SPEAKER_01:In that sort of scenario, we'd be thinking about starting at low intensities and low volumes and really gradually, as in like 10% at a time, increasing duration of activity before we increase intensity of activity.

24:16SPEAKER_02:That's a great summary. It's also hopefully nice for everyone to hear that those principles don't sound too dissimilar from our generalized exercise prescription principles as well. It's about knowing the patient's symptom modification, symptom monitoring and our exercise prescription principles. Jermaine, anything to add to what Bree's marvelously summarized?

24:40SPEAKER_00:No, I really enjoyed what Bree had to say about the IPN or peripheral neuropathy. And it's really great to see that evidence come through. And hopefully it gets published soon, Bree. So that'll be great. I guess one point I wanted to push slightly into was with the guidelines, the guidelines recommend exercise as part of standard cancer care. And it demonstrates that there is strong evidence for that two to three times resistance training and at least 30 minutes of physical activity, working up to 150 minutes of physical activity a week.

25:20SPEAKER_00:And that has strong evidence for improving symptoms like fatigue, mood, lymphedema, and strength, and all sorts of other symptoms as well, and moderate evidence for bone health and sleep. But it doesn't really give any kind of specific guidance as to dosage or even timing. And I think the guidelines does a really good job of providing that broad kind of umbrella recommendation so that every clinician knows what we can work our patients to to achieve those benefits in the long run.

25:56SPEAKER_00:But then the evidence I think is leaning towards the individualized timing as well. Because when I was working as a physio-delivering oncology rehab programs in the community setting and in hospitals, we'd have the physio, we'd have the EP, or we have the AHA there. And we could see up to eight to 10 patients in onk rehab, but only two would turn up. And so it kind of backs that question of it's not all one size fits all. We're asking patients to come along to a very structured, standard, time-limited program when we know that they might be struggling with that whole kind of fluctuating range of symptoms such as fatigue that might be because of treatments or other kind of stresses in life.

26:49SPEAKER_00:And so recent systematic review and meta regression we did, we asked that really simple question of when should exercise start if we really want to achieve that best kind of outcomes in terms of patients turning up. Because your program can be clinically effective, but if your patient doesn't show up, then your business is gonna shut down and your patients miss that on achieving those outcomes. And you know, it was really there was a really significant association with patient adherence levels really dropping when they were receiving treatment.

27:28SPEAKER_00:So it started high with adherence before treatment. So with prehabilitation, adherence was high, and then it dropped, and then it came back up after treatment had completed. And you'd think, oh, that's obvious. Obviously, patients would struggle with attending exercise when they're having treatment. But now we have really solid evidence across 176 trials were included in the systematic review, and it's it's under review at the moment as well. So hopefully, again, fingers crossed, it gets published in the next five to ten years with the right things are going.

28:05SPEAKER_00:Now we have really solid evidence to show that kind of trajectory. And we took one step further and we found that the adherence really, that pattern really stuck and was associated with a person's age, the type of treatment they received, and also age treatment and yeah, there's something else, but I can't really remember at the top of my head. But so it showed that older patients they were really good attending your exercise programs before treatment.

28:32SPEAKER_00:But mother started treatment and after treatment, it dropped compared to your younger patients. And that's quite really important. That's really important for us as clinicians to be aware of. And if you're working with these sort of patients, cancer type was the other one that had a real significant association. So your patients with lung cancer and collectal cancer really kind of had that dip in attendance levels compared to your breast cancer patients.

29:02SPEAKER_00:So, again, if you are a clinician who are who is working with older people or very specific types of cancer, these kind of patterns are really important to be aware of to help support your patients to keep going with that exercise, accommodating for these dips and fluctuations in things like fatigue and attendance and other factors as well.

29:28SPEAKER_02:Fascinating evidence. In terms of you've alluded to the cancer types that have a drop in adherence. Are there particular cancer types where the evidence around that link between exercise, cancer recurrence, and survival is stronger? Do we have evidence around that?

29:49SPEAKER_00:So with the ACSM, the American College of Sports Medicine Guidelines, I think they came out in 2018 or 2019. It showed that exercise had that benefit of reducing cancer recurrence, particularly for breast cancer, for prostate cancer, and I think two other cancer types. But these were based on associations of a large number of trials and systematic reviews. And so if you're talking about that direct effect of exercise on in a particular cancer type, then the challenge trial that was published last year would be your first kind of level one phase three RCT that showed that in the colon or colorectal cancer population, that was that direct link between exercise and reducing the risk of colorectal cancer coming back.

30:48SPEAKER_00:But essentially, across the research space, I think, yeah, Bri, correct me if I'm wrong, but I think the largest number of trials are usually in the breast cancer space. So you find that there's quite a bit of a skew in terms of breast cancer being represented quite largely in the research space, whereas your other kind of not so not so attractive cancers or your harder populations to do research on, like your lung cancer populations, are a bit more underrepresented in the research trials.

31:22SPEAKER_02:Brie, do you have any thoughts on that?

31:25SPEAKER_01:Yeah, I think you've summarized that really well, Jermaine. I think really important for us to be across that. We do have that epidemiological evidence, that sort of association evidence for some of the common cancer types that suggests that it's likely that exercise is associated with improved survival and reduced recurrence. But as Jermaine has said, colon cancer is the only cancer type that we have, that prospective causal relationship between exercise and that improved survival or reduced recurrence.

31:55SPEAKER_01:I think that it's important for us to be upfront about that sometimes because I know that I've already had research participants who have sort of come to me and said, oh, like exercise can improve survival, and I'm going to do this so that I can get the best and live the longest that I can. And that that may be very true, but I think understanding what the limitations of our evidence base in that space is at the moment is also really important. We do have other prospective randomized controlled trials that have been powered for survival, including like the echo trial, which was run here in Australia looking at ovarian cancer and other studies across the globe that have been run that were unable to demonstrate the same survival benefits for some cancer types.

32:37SPEAKER_01:That doesn't mean that survival benefit doesn't exist, but just that we haven't been able to demonstrate that yet. So finding a way to really have that sometimes tricky conversation about what we do know and what is likely to be the case, is a challenge for clinicians, I think. But yeah, a really important space. And hopefully we continue to gather more and more evidence over time. But as Jermaine said, some cancer types are really are going to be really tricky for us to capture that.

33:04SPEAKER_01:Breast cancer's got very long survival anyway. And so for us to measure survival is it would take a potentially a long time. And also the challenge trial, whilst being an incredible landmark trial, it was also incredibly intensive and very expensive. And so it will be hard for researchers to be able to replicate the same thing. So yeah, it's a really interesting space and an exciting space, but certainly something that I think we should sort of temper with, like a balanced view of what we really know.

33:30SPEAKER_02:Communicating the evidence accurately without necessarily overstating the potential benefits depending on the cancer. Yeah, absolutely. Thank you. I'd love both of your perspectives on this, and you've both alluded to this already in today's discussion, but what does equitable access to exercise services and supportive care look like in practice? And how can we work towards achieving it? Bri, I might throw to you first.

33:57SPEAKER_01:Yeah, absolutely. So I think this is probably one of the most important questions of our sort of time in at least in exercise oncology. We've spoken a bit about how we've got this incredible evidence base now that it's been built up over the last three decades or so to show that exercise is really beneficial. But we still know that most of that evidence is has been collected in more well populations, like breast cancer populations and typically those who have earlier disease.

34:27SPEAKER_01:And also we know that the bulk of the evidence has been collected in often metro areas, so people who live in cities or close to cities, and also in higher socioeconomic status groups. And so we have this issue where we don't necessarily know that people who really need exercise and rehab services can access them across all groups, so particularly those who might be living in regional or remote areas, people who might have come from lower socioeconomic backgrounds or low health literacy backgrounds.

35:01SPEAKER_01:And so for me, it is really about how can we improve access to services for everybody, particularly those who might come from those more marginalized groups. And one of the key things that we're really interested in is how can we improve referral pathways and part of so we can improve access to the community services from the hospital to the community. So we're interested in sort of bridging the gap between care in the hospital and then community-based services.

35:30SPEAKER_01:We know that people tend to fall through the cracks. So they often get good care in the hospital, they have access to perhaps physiotherapists, maybe an exercise physiologist in an inpatient or an outpatient program. But once they leave the hospital, sometimes they're not able to make it to the community-based services, and whether that be because they haven't received a referral or they can't afford the cost of the care. And so we're interested in understanding what the barriers are and how we can improve in work on removing those barriers so that people can have better access to ongoing care in the community.

36:07SPEAKER_01:As I said, the referral pathways is something that we're really interested in understanding. And we're also interested in how we can improve workforce capacity. So improving networks between professionals in the community, because we know that like peer-to-peer education and peer-to-peer mentoring is something that can really improve confidence and improve skill sets in clinicians and allied health professionals.

36:30SPEAKER_00:You know, there's so many barriers to access that just have been there since day one. And, you know, when you talk to cancer patients, they often tell you, I can't come to, you know, your exercise program because your exercise program is in the hospital. I have to travel, there's no parking around the hospital, or, you know, there's other barriers like, oh, you know, I don't really want to be exercising out in the community because I'm not sure if it's the right program for me, because you're not part of my treating team.

37:07SPEAKER_00:And so these are some of the barriers that we often hear and challenges that we face. And I think, yeah, Brie's definitely right about the referral pathways often being quite ad hoc. We know that if you're lucky, your oncologist talks to your patient about exercise and brings it up in their consult. And we know that patients are more likely to accept going to exercise if they hear it from the oncologist. But it's very, it's a lottery at the moment.

37:39SPEAKER_00:If let's say you get a referral to oncology, rehab, or exercise support. And so, you know, that idea of exercise that should be standard care is still not quite integrated in the way that we want. Um, referral pathways are tedious in the sense that there are lots of hoops to jump through when you want to refer someone to exercise. And often there are lots of things like waiting times for a spot in an exercise program. And so these things kind of set, set up more barriers in the process.

38:15SPEAKER_00:And so I think if let's say you are a clinician wanting to improve the access for some of the cancer to start exercise early, it's you know really kind of addressing some of these key barriers, like reducing that waiting time from when a person gets referred to actually you contacting the patient and offering them a spot in their in your program or making it actually tailored to a way that they can come to your program without having those financial um or travel barriers, which often a lot of patients face.

38:52SPEAKER_00:And I guess, yeah, with all with all the other populations that are underrepresented, things like language barriers as well. We have a large multicultural population in Australia. And so a lot of the times their understanding of exercise and the benefits of exercise after cancer diagnosis are not properly addressed. And so I think Ling Your referred to you can be a really good strategy as to how to improve that access.

39:23SPEAKER_02:A great summary from both of you with some great action points. Thank you both for such a thoughtful discussion. I think what's really clear from today is that exercise and rehab have an important role throughout the cancer journey. And there's no one size fits all approach, as with many things, and it requires that individualised prescription, there's strong clinical reasoning and collaboration across the multidisciplinary team. And as you've both spoken about, importantly continuing to improve access means that hopefully more people affected by cancer can benefit from the evidence that we already have.

39:59SPEAKER_02:So thank you both. Thank you so much. Thank you.