Innovative rehab revitalizes patients in their battle against disease

CNR team
The McGill Cancer Nutrition Rehabilitation Program team, led by Director Dr. Thomas Jagoe (rear). From left, Physiotherapists Leo Culhane and Anh-Thi Tran, Dietitian Rima Nasrah, Nursing Counsellor Monica Parmar, Dietitian Christina Van Der Borch, Clinic Coordinator Mary Kanbalian and Nurse Navigator Natalie Leon. Not pictured: Physiotherapist Tamara Windholz.

Often, the key is to provide each cancer patient with a custom-designed regimen of revitalizing physical activity and healthful eating habits, along with access to healthcare and social service professionals that can guide patients in improving their quality of life.

Among those at the vanguard of this approach is the McGill Cancer Nutrition Rehabilitation Program Clinic (CNR) at the Jewish General Hospital. “As cancer treatments have got steadily better at controlling cancer and people are living longer because they are receiving more treatment, these chronic problems become more prominent and the need to treat them has become even more pressing,” says CNR Director Dr. Thomas Jagoe.

Reimagining rehabilitation

“The strength of our clinic is to be fully integrated into oncology care,” notes Dr. Jagoe, a Pulmonologist at the JGH. On hand at the clinic to provide combined therapy services is a multidisciplinary team that includes a physician, nurses, dietitians and physical therapists.

CNR assessment
Mary Kanbalian, Clinic Coordinator, checks a patient’s weight.

Team members greet new participants to the out-patient program with an assessment, an important first step in establishing well-rounded, personalized and flexible interventions. They calculate the patient’s height and weight, discuss their symptoms, and gain a better sense of their lifestyle. Patients that take part in the program can be at any stage of cancer, but most have advanced cancer. The team examines the patient’s medical chart, to become familiarized with the participant’s medical history, as well as to flag any underlying problem that might exacerbate unpleasant symptoms. For example, Dr. Jagoe describes the scenario of a patient who suffers a fall. Did this accident happen because the patient is weakened by their cancer treatment, or because the steps in their home are steep and dangerous?

“Another dimension of our screening involves a risk assessment,” explains Dr. Jagoe. “It may be that a decade earlier the patient was prescribed medication to lower their blood pressure, but is no longer needed if that person has since lost a considerable amount of weight. In such an instance, if they do continue on the drugs their blood pressure may drop too low, which can lead to symptoms such as weakness and dizziness.”

Nutritional health: a vital supplement to care

Once the CNR physician, nurse, dietitian and PT have met with the patient and reviewed their file, they collectively develop a rehabilitation plan whose goal is to help the patient gain their capacity and independence. The plan is progressive, Dr. Jagoe points out, carried out according to a proper sequence, beginning with the ‘weight issue’.

The dietitians at the CNR clinic perform a nutritional assessment on the first visit, which examines the patient’s weight and diet history. To better understand their client’s food choices, the dietitians also consider the patient’s food preferences and dislikes, cultural background, financial status, and social network (to determine, for example, who prepares their meals or does the grocery shopping). “We often ask patients what they ate the day before our clinic, to get an idea of the quantity, quality and composition of their diet,” says CNR Dietitian Rima Nasrah, who has been with the team since 2013.

CNR Dietitians
Dietitians Christina Van Der Borch (left) and Rima Nasrah review the text in an information pamphlet for patients.

Other factors that might affect their food intake include medical conditions and symptoms. For example, a patient might be eating poorly due to nausea or difficulty swallowing, related to their disease, its treatment or possibly both. Once the assessment is complete, the dietitians recommend an appropriate, personalized nutritional plan to correct any nutritional deficits and ultimately help the patient stabilize or increase their weight, minimize muscle loss and improve their overall nutritional health.

“The whole CNR team works very closely together to improve our patients’ quality of life—it’s really a collaborative effort,” says Dietitian Christina Van Der Borch, a 12-year veteran of the program. “For example, for someone with nausea, we don’t only consider how to modify their dietary intake to diminish their symptoms, the doctor or nurse will also manage any medications that can help.” Beyond their weekly multidisciplinary rounds, the CNR team also liaises with healthcare professionals both at the JGH and in the community, in developing a patient’s nutritional plan and following their progress.

These individuals include:

  • Chemotherapy dietitians or dietitians in the community
  • Occupational therapists
  • The hospital treating team, including physicians and pivot nurses
  • Dentists to evaluate and intervene for poor dentition or advice on prostheses, which may become loose and ill-fitting after severe weight loss
  • Oncology pharmacists, who for instance clarify whether certain natural health products, herbal supplements or foods interact safely with the patient’s medications
  • Speech language pathologists, who help the team further assess swallowing difficulties
  • Various other professionals or organizations, such as social workers or Hope & Cope, if a patient has trouble with finances or accessing food

Specialists provide crucial input in a patient’s nutritional plan, say the CNR dietitians, but the team never neglects to consult another key contributor: the patient themselves. “We pride ourselves in including the patient in goal setting,” says Ms. Van Der Borch. “For example, a patient may just want to be less fatigued, to be able to play more with their kids, or perhaps return to work. We help the patient get there by addressing that particular symptom, if that’s what they feel will most contribute to their quality of life.” To help assure the plan’s success, adds Ms. Nasrah, “We work together with our patients to set up realistic goals, and follow up to ensure that they are able to carry out our recommendations.”

Getting the patient on track with a customized exercise program

Physiotherapist Thi Tran advises Helen Rainville Olders on proper exercise techniques.

Once the patient’s dietary regimen is on course, physiotherapists specialized in the care of cancer patients perform a full assessment of the client’s physical abilities. Does the patient have a bad shoulder or overall weakness? Or perhaps chemotherapy-induced neuropathy, which involves changes in sensation primarily of the hands and feet that can impact dramatically on a patient’s balance or physical capacity? Any vulnerabilities are factored in to the individualized exercise program developed by the PT.

Physiotherapist Leo Culhane helps Marc F. Tremblay improve his weight-lifting technique.

Under the rehabilitation staff’s close supervision, the patient will take part in physical training to prevent muscle wasting and maintain their cardiovascular endurance. Boosting the patient’s strength and stamina allows them to more securely carry out activities of daily living. 

“The gym plays a crucial role in the patient’s rehabilitation,” says CNR physiotherapist Leo Culhane. “Patients are not only feeling invigorated after their workout, they are also enjoying the social aspect, seeing other patients, meeting with the team. The gym isn’t vast and intimidating, it’s such a pleasant and intimate space, the patients find it uplifting.”

As a complement to their rehabilitation training, patients in the program may partake in Qi-Gong exercises led by CNR physiotherapist Anh-Thi Tran, who is qualified in traditional Chinese Medicine. Mr. Tran also offers non-invasive acupuncture, which he says promotes relaxation and is a safe and effective method of decreasing nausea, pain, anxiety, insomnia and depression. “When we’re involved in the patient’s cycle of therapy, we give them a much needed rest in their treatment,” says Mr. Tran. “It’s a tremendous help to their morale.”

Nurses support patient throughout trajectory of care

“To empower the patient is always our end goal,” says Oncology Nurse Navigator Natalie Leon. “Building that collaborative partnership is the hallmark of nursing.” The nurse’s role in the CNR program is to guide patients, whether by providing education when needed or by connecting patients, family and caregivers to support services within the community.

“Exploring a patient’s emotional well-being is what guides my daily clinical practice,” says Ms. Leon. “Diminished function isn’t only caused by feeling physically depleted. It’s not uncommon for cancer patients to experience anxiety or become more isolated and inactive socially, they feel ‘I can’t get up, I can’t get to work’.” In such instances, they enlist the expertise of psychologists or social workers to provide psychosocial counselling. If the patient is discouraged because they do not even feel secure moving around their own home, the clinic’s nurse might coordinate care with an occupational therapist from a CLSC, who will, for instance, visit the patient’s home to place grab bars. All of these interventions are with a view to helping the patient more confidently and comfortably perform the activities of daily living.

CNR Nursing
Monica Parmar, a Nursing Counsellor, meets with a patient.

“The primary impact of our clinic is that it has challenged patients’ assumptions about the symptoms that they experience. The extreme fatigue, the weight loss—these do not have to be the expected trajectory of receiving good cancer care,” Ms. Leon claims. “Patients often tell me they believed it was normal to have a loss of appetite, as an indication the chemotherapy is working. This is not true. Exercise, good nutrition and psychological health are lifestyle changes that can be achieved with proper instruction.”

“Our clinic offers these valuable tools to the patient. Once implemented, I have seen first hand the impact on the patient’s quality of life, no matter their age, socioeconomic background, or additional medical conditions. This is the value in our interdisciplinary care, our patients tell us, ‘maintaining my quality of life is imperative for me to fight this cancer battle’. They are restored to levels that allow them to enjoy activities outside the home, even while actively undergoing therapeutic treatment.”

It’s all part of the plan: clinic offers quality care

These gains are not simply conjecture. They are supported by the team’s reliance on the most current, evidence-based practices, as well as data collected through various research projects carried out by members of the CNR team.

The clinic is classified by the Quebec program for the fight against cancer (PQLC) at level four, designating the highest level of care. “Our interdisciplinary treatment plans are built on the best available evidence,” says Ms. Nasrah. The clinic conducts ongoing research studies in parallel to working with patients, relating to anything from the assessment of muscle mass in cancer patients, to the relationship of gut bacteria to cancer-related weight loss. “We’ve also recently published our findings on patient outcomes that confirm the effectiveness of our targeted nutritional counseling in helping cancer patients to increase their food intake. Further, we’ve shown that weight gain and an improved ability to carry out daily tasks correspond to an improvement to our patients’ quality of life.”

The research projects at the CNR are grounded not only in practicing but also in sharing evidenced-based research with staff and patients, says Ms. Leon. “Many of our projects have been presented in international forums, as we continue to strive to be up to date on clinical recommendations for best practices, which form the basis of our counseling to patients and family members.”

Welcoming patients into clinic’s avenue of care

Each year the clinic receives into the program approximately 120 patients. The team is keen and equipped to help even greater numbers of cancer patients. “The medical community doesn’t necessarily know that we’re a resource,” says Dr. Jagoe. “We’d like to send a message to our CIUSSS colleagues—if they’re struggling to help a client with cancer that is suffering from the effects of their condition and treatment, direct them to us.”

Patients who spent far too long beset with fatigue say they wish they’d known about the program sooner, says Mr. Culhane. “They come to us, and once their treatment plan is underway, they feel the benefits to their quality of life.” Ms. Leon points to a patient testimony from this spring, crediting the CNR team, “Thank you for helping me feel better and getting me back to who I was! Words cannot express my gratitude!”

To refer patients to the CNR clinic, CIUSSS staff may contact Clinic Coordinator Mary Kanbalian at 514-340-8222, extension 23150. Alternately, consults may be faxed to 514-340-8738.