Dr. David Langelier
"Patients deserve a unique lens to look at their impairments, and guidelines for how we address them," says Dr. David Langelier, a cancer rehabilitation physician at UHN. (Photo: UHN)

Dr. David Langelier is on a mission to make cancer rehab a standard of care in Canada and beyond.

"There is an enormous disability that comes with fighting cancer," he says, referring to symptoms such as frozen shoulder, lymphedema, and myofascial pain, as well as fatigue, emotional struggles, and difficulty getting back to work.

"I became a cancer rehabilitation physician to address these impairments and help make people more functional."

It's a personal goal he set long before graduating from the University of Toronto's Faculty of Medicine, as the first cancer rehabilitation physiatrist trained in Canada.

"Most of us have loved ones who have experienced cancer, and my own family is no different," says Dr. Langelier.

"What brought me to where I am now was seeing treatment be very effective, but realizing there wasn't a lot available to deal with the side effects."

There was also a dearth of research to help guide this care.

"We're borrowing evidence from other populations to make decisions in the field without knowing if it's proven in the cancer population," he says.

"Patients deserve a unique lens to look at their impairments, and guidelines for how we address them."

As a clinical investigator, he's filling both gaps, by caring for patients today, and establishing proven, best practices for tomorrow.

The growing need for cancer rehab

While cancer rehab isn't a new area of medicine, demand among patients has steadily grown as treatments become more targeted, surgical approaches more aggressive, and survival rates rising.

UHN's Cancer Rehabilitation Program, which bridges care between Princess Margaret Cancer Centre and Toronto Rehab, was born from listening to patients and responding to their demands.

"Our goal is to improve functional impairments caused by cancer treatments, through rehabilitation, exercise and medical management strategies," says Dr. Eugene Chang, the program's medical lead.

"As an academic institution, we want to push the envelope beyond clinical care.

With my focus on education, and David's on clinical research, we're moving from being a program that knows cancer rehab works, to one that can prove it."

The right care for the right patient

"Just like oncologists use immunotherapy to deliver precision medicine, we're developing precision medicine for cancer rehab," says Dr. Langelier.

"This will ensure that the right treatment is directed to the right patient."

At Princess Margaret, he's researching how patients with advanced cancer can safely exercise to improve quality of life during their palliative stage, or become eligible for further cancer treatment.

He also consults on inpatient units and in the Cancer Rehabilitation and Survivorship Program, assessing patients for rehab potential and screening for physical, emotional, vocational and psychosocial impairments.

Together, they explore reasonable rehab goals based on the timeframe patients are given.

"David's approach is warm and person-centred," says Patrice de Peiza, an occupational therapist (OT) who works across both programs with Dr. Langelier.

"The time he takes to explain options decreases the power differential between patient and doctor, and gives patients a sense of control over the direction of their treatment."

At Toronto Rehab, he practices in the Electromyography (EMG) Clinic bringing an awareness of cancer treatments and their various complications to the team.

"David has enhanced both our service delivery and core residency teaching by being the go-to person for cancer and cancer-care related manifestations of nerve and muscle disorders," says Dr. Tania Bruno, Neurophysiatrist and Director, EMG.

"As an added benefit, he provides valuable continuity of care for his cancer rehabilitation patients who may need electrodiagnostic evaluation at our clinic."

He's also creating a research program within RESTORE, an education and aquatic-based exercise program, developed by Patrice with support from Dr. Chang for people with cancer who have problems in the shoulder area.

Since 2017, the team has been collecting data that looks at range of motion, pain, disability and quality of life measures.

"We're seeing patients get better, but we haven't been able to prove it yet," says Dr. Langelier.

"We're sitting on something unique, that could potentially be licensed out and delivered at other institutions across Canada."

Research coming out of RESTORE, an education and aquatic-based exercise program for people with cancer who have problems in the shoulder area, will help UHN share knowledge with other institutions. (Photo: UHN)

Today's building blocks lead to tomorrow's Healthier World

Dr. Langelier knows that propelling the field of cancer rehab forward requires more than the evidence to support it.

It also relies on awareness and referrals from oncologists, funding for fellowships to build expertise and person-power, and the ability to educate healthcare providers, from OTs to family physicians, on how to diagnose and treat cancer-related impairments.

To that end, he and Dr. Chang are advocating for the development of Project ECHO for cancer rehab, a non-profit, Ministry of Health funded virtual education platform that would help disseminate knowledge being built at UHN, and empower care providers to address issues at their local level.

He's also trying to create an international cancer consortium among cancer rehab physicians to develop best practice guidelines that will dictate how impairments are uniformly treated.

"In a dream world, we would have more universal coverage for outpatient cancer rehab," he says.

"Because ultimately, I suspect that readmission to hospital and failure to return to work stem from chronic impairments that could have a solution – and it lives in a rehab space."

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