Ep. 20 – Head and Neck Oncology Care – Lymphedema, Fibrosis, and Research Breakthroughs with Holly McMillan on Interview – S4OM Collaborative Connections

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[00:00:55] Introduction and Greetings

[00:00:55] Ericka Clinton (she/her): Good day everyone. Collaborative connections is back. [00:01:00] Welcome to another episode. It’s been a long time we’ve missed you. But we have a really exciting podcast today and I’m so glad to bring this back to you from the Society for Oncology Massage and the Society for Oncology Aesthetics. My name is Erica Clinton and I’ll be the host.

[00:01:20] Guest Introduction: Holly McMillan

[00:01:20] Ericka Clinton (she/her): And on today’s podcast we have Holly McMillan. Okay, collaborators, wait for this bio. Holly McMillan is a senior research speech language pathologist and co-director of Christmas clinic at the University of Texas, MD Anderson Cancer Center. She is a doctoral candidate at the University of Texas School of Public Health, a licensed massage therapist and certified lymphedema therapist with expertise in oncology and head and neck cancer rehabilitation. Holly leads the manual therapy service lines within the head and neck surgery department and specializes in fibrosis and lymphedema management. She is a co-investigator and collaborator on several active NIH funded clinical trials in Head and Neck Cancer survivorship. Holly, thank you so much for taking time to join us today.

[00:02:26] How are you?

[00:02:28] Holly McMillan: Of course. Thank you for having me.

[00:02:30] Ericka Clinton (she/her): so about a month ago, you reached out to S four OM regarding several research articles you had authored, and when you explained your professional background, I was absolutely amazed and I thought I have to do a podcast with Holly. Our listeners are absolutely going to be blown away. So really, really glad you came on today. But I’d love to start with having people get an understanding.

[00:02:57] Holly’s Journey: From Massage Therapist to Doctoral Candidate

[00:02:58] Ericka Clinton (she/her): of of you. So could you [00:03:00] explain to us how you went from licensed massage therapist to speech pathologist and now doctoral candidate?

[00:03:10] Holly McMillan: Of course it sounds like it’s actually a question of did I find my passion through fate or mistake? And the actual answer is mistake. So back in 2004 let me not date myself back in 2004 when we applied to college at that point, I don’t know if you remember, it was just a click box and then a generic description of yourself.

[00:03:32] So I accidentally clicked speech pathology when I meant to apply for special education. In undergrad. So I clicked the wrong box and then fast forward to my first speech pathology class. Fell in love, it was meant to be. Moved through school and then finished my fellowship actually up in Seattle.

[00:03:54] And I just felt like I was missing a large component of [00:04:00] treatment. Something was missing. There was a tool and it, it turns out that tool is actually touch. Which then just spiraled beautifully out of control into lymphedema fibrosis, all of these different realms of touch that we all know and love.

[00:04:14] And then fast forward again, I’m now yes, at MD Anderson Cancer Center, and I’ve been here for almost a decade now, the co-director of Christmas Clinic, which is just such a passion of mine within the Department of Head and Neck Surgery, and now getting a PhD in epidemiology and biostatistics and leadership because.

[00:04:32] One of two things is true. I either love the never ending curiosity wanna take a deeper dive into research, or I just love student loans. I haven’t recited which one yet, but one of the two. I keep going back to school.

[00:04:45] Ericka Clinton (she/her): Oh my gosh, that’s, that’s wonderful. And so interesting that again, it was like a moment in space and time that was quote unquote an error

[00:04:55] led you to the thing that you really love.[00:05:00]

[00:05:01] Holly McMillan: Yep. Yep.

[00:05:02] Focus on Head and Neck Cancer Rehabilitation

[00:05:02] Ericka Clinton (she/her): So you’re considered an expert in head and necks cancer rehabilitation. This is a cancer that’s particularly challenging for many, many reasons. Can you explain why this particular cancer became your focus?

[00:05:19] Holly McMillan: Absolutely. I, I couldn’t agree more. The, the real estate. For head and neck cancer is tighter than the New York City skyline, which makes it an exceptionally challenging landscape. I, I fell in love with head and neck cancer because as a speech pathologist, our training specializes in the anatomy, physiology, and function of the head and neck.

[00:05:40] And this performs, you know, our most vital functions like communication and swallowing. So it was really just a natural shift for me to explore this cohort in oncology for head and neck.

[00:05:50] Ericka Clinton (she/her): . So you specialize in fibrosis and lymphedema management.

[00:05:56] Challenges and Prevalence of Lymphedema and Fibrosis

[00:05:56] Ericka Clinton (she/her): Are those conditions common amongst head and neck cancer patients?

[00:06:00] Holly McMillan: Unfortunately um, GIA Dang, Barb Murphy, Sheila Ryner, the group out of Vanderbilt. They put out really nice, publications in this space. And most recently they published prevalence rates and unfortunately, internal and external lymphedema. So both in the digestive track and what we can palpate on the outside.

[00:06:21] Prevalence rates are about 90% of patients that are undergoing radiation therapy. Yeah, so a lot of patients. And then about a year after is when they marked fibrosis, and that’s at about 75%. So unfortunately these prevalence rates are quite high. So we haven’t seen, even with the amazing advances we’ve had in cancer care, these rates are still exceptionally high.

[00:06:44] Ericka Clinton (she/her): Okay. Is there an understanding why? Particularly with head and neck cancer patients and radiation. I mean, I can come up with my own story, but like what is there evidence-based research that really says this is why this population is so at risk for both of those [00:07:00] conditions.

[00:07:00] Holly McMillan: We we’re currently looking at sort of advanced metrics on that TGF beta response, different biomarkers to better understand that. But we do know that head and neck is rich in lymphatics, so any sort of damage to this area, we know that we have a hundred or. 800 to a thousand, excuse me, lymph nodes in the body and over 300 of those are in head and neck.

[00:07:20] So we are lymphatic rich and when we damage that system, either diffusely with radiation or we, you know, take out nodes, cut vessels with surgery, we are at high risk for damaging that structure system. Yeah.

[00:07:33] Manual Therapy Techniques and Patient Education

[00:07:33] Ericka Clinton (she/her): how do you as a manual therapist support patients with either problem?

[00:07:42] Holly McMillan: That’s a great question. In my opinion, education is, is really where we start especially to the physicians, the advanced practice providers, so the, the. Physician’s assistants, the RNs, they are our biggest allies in helping them understand the screening [00:08:00] process. Whether it’s physical manifestation, how to palpate lymphedema, how to palpate fibrosis, or to understand when your patients are reporting these symptoms.

[00:08:08] That’s the time to refer. We like to talk to them about who’s at risk in case they want to send before they see these indications, because we know the prevalence rates are so high. But educating our friends and our colleagues to get the referrals in on time is, is probably one of the best ways we can support these patients.

[00:08:25] I’m in a unique position in that most patients here to me are not local. So me as a an individual provider, I schedule back-to-back appointments when I’m meeting them for the first time. I do my initial evaluation, I go right into treatment. I focus the treatment, not so much on me treating that patient, but teaching them how to do a home program.

[00:08:46] These are chronic conditions, they won’t go away. Seeing me three times a week is just not feasible. I need them to work on these things seven days a week. So I love to, in that initial session, I want them independent with this when they [00:09:00] go home, if they come with a spouse, a partner, a family member. I also love integrating touch into healing.

[00:09:08] So training. Family members in how to do, you know, manual emphatic drainage or you know, scar release, whatever it is that we’re doing. I love integrating that into our session as well. So whenever I can involve families I do, when they come back for repeat treatments, some patients are local or they come back frequently enough, I can see them, I’ll treat them, but it’s always with at-home treatment as well.

[00:09:32] So I like to hand the reins over to them so they feel like they have some control over these conditions.

[00:09:37] Ericka Clinton (she/her): I’m sure empowerment is big part of the management process. besides having everyone aware of what the concern is and what to look for is giving the patients the ability to kind of advocate for themselves through their own therapeutic intervention. It’s great that you have people along all of those [00:10:00] interactions who wanna support making sure. Because as, as you said, the earlier we get to it, oftentimes the, the best outcome that’s possible can be achieved.

[00:10:12] Holly McMillan: That, that’s absolutely true. And even in the pre-treatment. So patients go through a lot of pre-treatment like pre, pre radiation, pre-op appointments here, and again, when the. These providers, see these patients before and educate them, this is what we’re looking for. These are the signs. Swelling is very scary after a cancer diagnosis, but when you empower those patients to understand you have a high risk of developing lymphedema, it just makes it less scary.

[00:10:38] It doesn’t mean the lymphedema goes away, but it settles their mind a bit that, Hey, this is something we can tackle on the backend. We’ve got this covered.

[00:10:46] Ericka Clinton (she/her): And I’m sure they feel very confident that they know they have you and all the other folks at MD Anderson who are, who are ready to support new development, I guess, as they [00:11:00] go through treatment. You did some recent work with Dr. Geoff Bove. Uh,

[00:11:05] Research Insights: Palpating Tissue Changes

[00:11:11] Ericka Clinton (she/her): I think you were highlighting that tissue change can be palpated after radiation treatment even when blinded, which I, I’m fascinated by. Can you tell us a little bit about how you came to that conclusion?

[00:11:20] Holly McMillan: Yes, yes. So, Dr. B ove brilliant researcher, he radiated one rat limb on 16 rats, and then some rats were massaged, some rats were not. After eight weeks or eight weeks after radiotherapy. And, and the massage he assessed. Serum inflammatory markers, histology of tissue fibrosis, nerve pathology, electrophysiology, discharge, all of these wonderful metrics.

[00:11:49] And then brought me in to blindly palpate. These, these little tiny limbs, little, little tiny rat limbs would’ve been easier, you know, if it was, you know, like a human, a [00:12:00] quadricep, but little tiny limbs. And there are some funny photos floating around. He literally put a bag on my head, so I was literally blinded and then feeling these little tiny rat limbs.

[00:12:10] But yes, it was that with a hundred percent accuracy could identify the irradiated tissue. And it’s important to note, there was no visual, I couldn’t see anyway, but there was no visual change. It wasn’t that some had hair and some didn’t. It was actually palpation of the, the tissues. Interestingly.

[00:12:30] That was phase one, it was a hundred percent accurate. In phase two, he told me which limb was irradiated and then asked me to palpate to discern which limbs were treated with manual therapy and which were not. And what’s interesting is I could not palpate the difference between which limbs were treated and not only that they were irradiated or not.

[00:12:49] So it’s just an interesting sort of sub finding. And yeah. And this is the first work that we know of. That supports in a blinded fashion that we [00:13:00] as manual therapists can palpate change after radiation again, with a hundred percent accuracy, with or without correlating pathology. So this is sort of a huge finding.

[00:13:09] We felt because this is, this is giving some objectivity into a space that, you know, has been questioned before. So we were quite excited by those findings.

[00:13:19] Ericka Clinton (she/her): Interesting. Can you tell us I guess what you felt that told you this, the tissue had been irradiated.

[00:13:28] Holly McMillan: Yeah.

[00:13:28] Ericka Clinton (she/her): on this like little tiny arm.

[00:13:31] Holly McMillan: it, they’re so tiny. They’re so tiny. And it’s, I love, I love that I’m, I’m speaking to you in a group of people where I can say this and not get an eye roll. How when you just close your eyes and feel the tissue tells you, there’s so much you can feel in your fingertips and you just don’t have the words to articulate it.

[00:13:54] It’s in that space.

[00:13:55] Ericka Clinton (she/her): Wow.

[00:13:56] Holly McMillan: You, you know, you say that on a podium to oncologists, they kind of roll their eyes, but [00:14:00] not to this group. They understand what I’m saying.

[00:14:01] Ericka Clinton (she/her): okay. Um,

[00:14:02] Holly McMillan: But what’s interesting is he, he asked me, he said, can you quantify and describe what you’re feeling in these tissues and. On every irradiated limb.

[00:14:12] I was using words like smaller, more dense and atrophied. Tho that’s what I was feeling. The tissue was more firm and smaller, but he and I are interesting. We come from two different backgrounds. He was looking for fibrosis. ’cause he works in animal models. I work in humans and I’m thinking with my clinical hat, there’s no way this is fibrosis.

[00:14:34] This is only eight weeks after treatment. And he’s thinking, I’ve seen fibrotic changes in the biomarkers. And it was really fun to work with him since we had two different schools of thought. But consistently things were smaller and more dense. They, the tissues felt sort of dehydrated, if you will.

[00:14:52] Ericka Clinton (she/her): Okay. That is really interesting. ’cause of course, as you said it, I was like, right. This was only eight weeks after they were radiated, [00:15:00] so. And, you know, there is a lot of discussion about radiation, radiation, fibrosis and just the thought that it would take much longer to settle

[00:15:12] in. And although the, the subjects were quite small, it’s, it’s similar tissue.

[00:15:18] Similar tissue, so, um.

[00:15:21] Holly McMillan: is.

[00:15:21] Ericka Clinton (she/her): No, it just, it

[00:15:22] starts,

[00:15:23] Holly McMillan: what’s

[00:15:23] Ericka Clinton (she/her): thinking about all your oncology clients and being like, oh my goodness. Okay.

[00:15:28] Holly McMillan: yeah. I, I went in with the bias, this is not gonna be fibrosis. He went in with the bias that it was, and he, he was sort of frustrated in the project. Because when he did all of those amazing tests on the tissue. The only thing that came back significant in the assay was that the inflammatory mediator panel suggested that there were lowered inflammation levels in the tissues that were massaged, but no other biomarkers came back positive for fibrosis.

[00:15:56] So it just points out we’re feeling something, [00:16:00] it wasn’t fibrosis, but consistently we can feel the difference in the tissue. And could it be edema from. Inflammation. Absolutely. Could it be lymphedema? Absolutely. The test wasn’t set up and it wasn’t sensitive to those. So it’s not that they, they weren’t there, they just weren’t tested.

[00:16:18] So, I think in the next round we need to look at the edema and lymphedema biomarkers. ’cause we’re feeling something.

[00:16:25] Ericka Clinton (she/her): Yes, and there’s a whole conversation that can happen after that in terms of understanding how tissue responds to radiation in more in depthly, and then is there an opportunity to get ahead of some things. So that’s. That’s fascinating. And I went to the International Massage Therapy Research Conference.

[00:16:44] So I saw, I saw those pictures of you with the paper bag over your head.

[00:16:47] Holly McMillan: Those pictures made it to slides. Oh no. Were they on his slide deck?

[00:16:51] Ericka Clinton (she/her): He put, he just, just one, just one in the slide. And when

[00:16:55] he did the presentation, we were all like, oh, okay. Okay.[00:17:00]

[00:17:02] Holly McMillan: That was me under the bag.

[00:17:05] Ericka Clinton (she/her): I know you might have talked to him about that, just, just a little story.

[00:17:08] Holly McMillan: Yeah. Disclosure slide. Yeah. Okay.

[00:17:11] Ericka Clinton (she/her): So when I knew I was gonna be talking to you, I reached out to two educators who are huge fans of your work. Ask them if they had any questions they wanted me to ask you. And so I have two additional questions for you. One of them is from Janet Penney, who is an educator author, and she’s the curator of the S four oh M research page on our website.

[00:17:38] Intraoral Work and Its Impact

[00:17:38] Ericka Clinton (she/her): And Janet’s question is about the techniques used in intraoral work. So her question was, how precise are you in the specific structure you work on? How much pressure do you typically use and can you have an impact on swallowing and voice?

[00:17:58] Holly McMillan: Those are good [00:18:00] questions. Intraoral work is some of my absolute favorite. It’s very immediately rewarding in a number of cases. And in my opinion, this is especially meaningful when you’re in the mouth for function. I am very precise about where I work because again, of the real estate, the proximity to structures that are exceptionally fragile, potentially serious complications, if we manipulate things inappropriately particularly in the head and neck cancer population.

[00:18:32] There, there are receptors with the carotid arteries, internal jugular vein issues, styloid process. There’s a lot happening. So yes, I’m very. Very precise about which muscles I’m on. The gag reflect is also in there. We have to be careful. Patients don’t always like that. And I stay light-handed. I don’t, I do not use a lot of force or pressure the mouth particularly.

[00:18:55] This is such a great question. The mouth in particular is very vulnerable to [00:19:00] inflammation and poor healing after radiotherapy, so. When we induce manual therapy related inflammation, it can absolutely bring about a functional decline for our patients. And that can be in voice swallowing, more particularly probably speech and how the tongue moves around the mouth to the articulators.

[00:19:18] I always tell my patients, if you bang your knee and it swells, you’re gonna walk with a limp, right? Until that swelling results. If I go around your mouth and, and bang around. You could potentially have a limp and that limp can be in your mouth, opening in your articulation, swallow voice, moving food around your mouth, that kind of thing.

[00:19:36] So intentionally I stay very light to reduce the amount of inflammation I’m introducing into the mouth. And then that, I guess that sort of answered the question about can we see functional change in swallowing, voice speech, and Absolutely. I, I, I love manual therapy in the mouth for those indications.

[00:19:53] Yeah.

[00:19:54] Ericka Clinton (she/her): Okay. That is a great question. I do lymphatic work and I do intraoral work. And [00:20:00] to be honest with you, never thought about doing intraoral work with my head and neck clients, more lymphatic work because again, you see so much lymphedema, so much swelling. But now I’m like, oh, there’s something else to explore there.

[00:20:18] Holly McMillan: And I would say the number one, the number one thing too about in the mouth is lubrication. These patients, the number one oral morbidity is Xerostomia, and if they have dry mouth and, and manual therapists know this, but if they have dry mouth and we. Are in the mouth. It does not respond like external tissues.

[00:20:38] That tissue can rip, it can bleed, and the mouth is a bleeder. So it’s always important to take lubrication in the mouth when we are working, if we’re moving out of that lymphatic, well lymphatic space, a little bit different. But to use lubrication so that we don’t injure the mucosa lining the mouth ’cause it’s very vulnerable to ripping and tearing.

[00:20:57] Ericka Clinton (she/her): Oh my goodness. Can I ask what kind of [00:21:00] lubrication you would use?

[00:21:01] Holly McMillan: Yeah, my favorite is coconut oil.

[00:21:04] Ericka Clinton (she/her): Huh?

[00:21:05] Holly McMillan: Yeah, so always, always ask if they have a coconut allergy. But no, it tends to be a beautiful antifungal. There’s just a lot of good properties about coconut oil and it’s usually well tolerated when they still have significant sensitivity. So it’s always like the paint test.

[00:21:20] Have ’em try a little bit in a, in a small area to make sure they don’t have an adverse reaction. But then they tend to like it. Will it cure dry mouth? No, it will not. But does it act more like a lotion? And protect those tissues with a barrier a little bit better than something like water. Mm-hmm.

[00:21:35] Sure does.

[00:21:36] Ericka Clinton (she/her): Amazing. Thank you.

[00:21:38] Appreciate that. All right.

[00:21:40] Scar Tissue and Fibrosis Management

[00:22:02] Ericka Clinton (she/her): And from Kathy Ryan, who is an educator and scar tissue expert, her question is about scar tissue and fibrosis. So she asked, what are your thoughts on massage manual therapy, facilitating change? In mature scars and fibrosis and what those changes might be. I was with her actually this past weekend. She taught a scar class. And you know, in the class we talked a lot about this general thinking in science that once scar tissue or fibrosis is formed, it’s, it’s a done deal. Like there’s nothing else to do. So she wanted your opinion on that.

[00:22:20] Holly McMillan: I just recently met Kathy. It was so much fun. We were we had a lovely chat on the Thinking Practitioner podcast with Phil and I would love to nerd out with her over coffee and scars. I just think that would be so much fun. That’s for another day. I’m sorry, I digressed, but I I could not wait for that.

[00:22:42] I just, car scar tissue and coffee with her would be so much fun. Okay. Back to, sorry, your original question referring. Referring to, so this is my experience with head and neck cancer. That’s the realm. I’ll, I’ll speak to mature scars are stubborn. But [00:23:00] like any good relationship, that doesn’t mean some of them can’t change.

[00:23:03] It depends on the scar itself and the tissue around it. So if you have a patient flex into their scar, lean into sort of bring origin and insertion of that scar together. If there is extra tissue around it voila. We can, we can help that scar change if they bend into it and there is no excess tissue.

[00:23:24] We’re sort of limited for morphology change. In my practice, I have found that the love language for mature scars time, low load, long duration, stretching. Time under tension is really their secret. And that’s the sweet spot. Not pressure, not bullying them, not beating them up because they will win at least in the head and neck.

[00:23:46] And that’s my experience. So if we try to fight mature scars with pressure and force, my body starts hurting and so does my patient, right? The scar will win and we’ve just now hurt everybody. But low load, long duration, stretch. If the [00:24:00] tissue has no extra movement around it or, or pliable healthy tissue, and I, I see this more often in the mouth, particularly in the Christmas clinic.

[00:24:10] We have to get creative with time under tension. So we’ll build like. I’m in the oral oncology clinic, so I have access to a lab and we can build things, which is just incredible. But we build things that help patients remain under tension while they’re sleeping, which is the win, right? It’s not one more thing an adult has to do during the day, so we get buy-in from our patients there.

[00:24:29] But if the scar is definitive it, it’s a specific scar, not not diffuse scar tissue from radiation fibrosis. We’ll actually go to the operating room. The surgeons will cut the scar band while I perform massage under anesthesia to give more time and tension. And we bluntly with our fingers sort of help dissolve the ends of that so the scar tissue doesn’t grow back more aggressively.

[00:24:54] So if you think sort of cycles of tissue manipulation followed by passive range of motion [00:25:00] and time under tension, we do that with the surgical teams for definitive scars. Did I answer all of your questions? I’m sorry.

[00:25:07] Ericka Clinton (she/her): you did. And now I have like 12 more, but then maybe we just have to do like, mature scar podcast as well. So. that that concept though, is very clearly within the wheelhouse of most manual therapists. Tension over time, right?

[00:25:25] And yes. And gentle, right? The idea that scar tissue is, as cath would say, changeable, not breakable, right?

[00:25:34] We’re not about destroying anything. We’re about kind of manipulating that scar. Manipulating those different types of fibers

[00:25:46] and getting them to do something different.

[00:25:49] Holly McMillan: Correct. It is all about morphology change. And the way in my experience, again, that we’ve done that is over time intention. We’re not, we don’t break scar tissue, we just change the structure of it. And I have a [00:26:00] colleague, Richard Cardoso, who he always says this to patients, and it just resonates so well.

[00:26:04] If he takes a rubber band and he just keeps stretching it really hard, that rubber band’s just gonna snap. And now we’ve done more damage, but the rubber band didn’t go away. If we take that rubber band and put it around a book. For a week. At the end of that week, that rubber band will just be bigger, and that’s really what we’re trying to do.

[00:26:21] Ericka Clinton (she/her): That really is a good analogy. And

[00:26:23] everybody understands that ’cause we’ve all done that with a rubber band, right? We

[00:26:27] everybody, right? So we, we know that that change will happen. And I think when people can put things into context that way they trust you more.

[00:26:38] Right,

[00:26:38] They have

[00:26:39] faith in what you’re saying and that something will be different. And I think with head and neck patients sometimes just the awareness that something can be different is, is really important for them.

[00:26:52] Conclusion and Future Discussions

[00:26:52] Ericka Clinton (she/her): Thank you so much, Holly. This was. Absolutely fascinating. And now my mind is just [00:27:00] like running, running, running on different things that we could talk about. So I’m gonna be in touch ’cause I would love to do another episode either to talk about manual therapy research which is something that I think all of our listeners are pretty interested in. And maybe get you and Kath together and we can all nerd out about scars. That would be absolutely fun.

[00:27:21] Holly McMillan: Correct. It would be, it would be. Yeah. I just, I am, I’m, I wanna help break the understanding. We all learned it in school. We were all told you can’t change scars. Once it’s mature and it’s set in, there’s nothing you can do. But we see it time and time again in our clinic. Low load, long duration, stretch.

[00:27:39] We’re seeing it. We have objective measures to measure this change over time when we do it gently and we give enough time. So it’s exciting that we were seeing something different than what we’ve been taught previously.

[00:27:53] Ericka Clinton (she/her): Changing all of that one little movement at a time, [00:28:00] but

[00:28:00] Right?

[00:28:00] But it’s important that it’s changing. And the real people behind it benefit so much from the fact that we are willing to explore and question and say, let’s try something.

[00:28:13] Holly McMillan: You got it.

[00:28:14] Ericka Clinton (she/her): Yes. Well, thank you. As I said, thank you. Thank you so much, and to our listening audience, I hope you guys have a good day and you really enjoyed our podcast.

[00:28:31] Holly McMillan: Thank you so much for having me. It was a pleasure.

[00:28:34] Ericka Clinton (she/her): Really a huge pleasure. I can’t even tell you. I was just like, oh my goodness.

[00:28:43] ​