The trouble with activity trackers … or not.

A recent study (1) found that a high level of cardiorespiratory fitness (CRF) was associated with an increased risk for localized prostate cancer.  The reasons for this are unknown.  The researchers speculate that perhaps this group was more likely to undergo preventative screening or detection.  However, higher CRF still showed a 32% decreased risk of cancer specific death for lung, colorectal, or prostate cancers; or 68% decreased risk of death from cardiovascular disease (CVD).  Note: some cancer treatments can be toxic to the heart.

From: Midlife Cardiorespiratory Fitness, Incident Cancer, and Survival After Cancer in Men:  The Cooper Center Longitudinal Study.

Lakoski, S.G., et al. JAMA Oncol. 2015;1(2):231-237

Figure Legend: Cardiorespiratory Fitness (CRF) and Risk of Incident Lung, Colorectal, and Prostate Cancer.  The low CRF group is the referent group relative to moderate and high fitness.  The error bars for moderate and high fitness represent the 95% confidence limits.  Adjusted for age, examination year, body mass index, smoking, total cholesterol level, systolic blood pressure, diabetes mellitus, and fasting glucose level.

The authors distinguish CRF from physical activity (I believe research data for both could be provided by valid and reliable activity trackers):

“Cardiorespiratory fitness is also highly reproducible and objectively assessed via incremental exercise tolerance testing compared with physical activity, which is largely determined by self-report questionnaires [and/or activity trackers?].  A prior study demonstrated that CRF is be a more potent marker of mortality than physical activity.  As such, given the current study findings and prior evidence, we contend that measurement of CRF should be used more frequently in the cancer prevention setting.”

I agree.  Furthermore, I would like to see physical activity, CRF, or aerobic capacity assessed when the cancer diagnosis process begins.  How beneficial would it be to tie fitness to an actual biopsy tissue specimen?  It’s interesting that CRF in the Cooper Clinic Longitudinal Study was assessed by the duration of performance achieved on a maximal treadmill test (2).  Then, based on subjects’ performance time, maximal oxygen uptake (VO2max) and maximal METs achieved were estimated, not measured.  If estimates can be used to assess CRF then it’s possible that some activity trackers could also be used.  Granted, screening patients before a CRF test is recommended, but some activity tracking data may already provide an adequate assessment of CRF.  A few devices already assess VO2max using heart rate, and with acceptable errors (for field measurements) in the 6-7% range (11, 12).  Stratifying data from activity trackers may be an important part of sorting its value: data for showing a training effect requires good accuracy; less accurate data is probably acceptable to assess CRF; and, data for tracking physical activity volume (MET-hours per week, etc.) can perhaps be the least precise of these – particularly since current population research using questionnaires tends to overestimate actual physical activity (13).

In discussing limitations of their study the authors mention something I believe may be significant for exercise-oncology research, and which I think validated activity trackers may be able to provide data for:

“CRF was assessed years prior to a diagnosis of lung, colorectal, or prostate cancer or death in men diagnosed as having cancer.  Thus, it is not known how changes in CRF and related behaviors, such as physical activity from the initial preventive health care to cancer diagnosis as well as changes in CRF and physical activity after diagnosis, may have had an impact on these current findings.”

I believe that exercise during the time from cancer diagnosis until first treatment will be found to have a positive impact on cancer treatments, treatment side effects, and on survival.  Sophisticated activity trackers that also estimate VO2max, or measure heart rate variability (HRV), which is related to CVD, have the potential to provide data in and around the diagnosis/treatment time period.  Furthermore, they can provide data across more cancer types by doing it in a more cost-effective manner than mailing out questionnaires or doing a CRF test on every cancer patient.  One overlooked benefit of activity trackers is that consumers subsidize the data.

Some useable physical activity data already exists in activity tracking databases but sits there underutilized.  Most physical activity data needs standard medical codes to improve its interoperability.  Other data could be retooled by correcting METs, which could provide more accurate estimates of energy expenditure (4, 5, 6, 7, 8), population specific intensity levels (9, 10), and might influence adherence to exercise training programs.  Regarding METs, an issue for some researchers is that the ‘standard’ MET (3.5 ml oxygen/kg/min) was based on the measurements derived from one 70 kilogram, 40-year-old man (5), and then applied to survey research.  Conversely, some activity trackers use ‘standard’ MET values from the Compendium of Physical Activities, which are intended for survey research, to estimate the energy expenditure and exercise intensity for an individual, which the Compendium advises is not its intended purpose.

Besides valid data, another issue activity trackers face is how should data be displayed or reported within an Electronic Health Record (EHR)?  Doctors are already over-worked and many complain about the burden of EHRs, adding physical activity data to their workload and expecting them to do something proactive with it (without reimbursement too) is not going to happen.  Make physical activity data easy for doctors to accommodate: summarize activity tracker data into an indicator of ‘compliance‘ or ‘non-compliance‘ with recommended physical activity guidelines, and provide that to an EHR.  For research, and for the more inquisitive and less time constrained physician, the underlying data supporting a compliance indicator could be accessible via EHR patient portals (e.g. EPIC’s MyChart).

Finally, a new study (3) found the ActiGraph GT3X+ accelerometer not to be very accurate at low and moderate intensity levels.  Of the few validation studies done on accelerometer based activity trackers, some were validated against the Actigraph as the criterion measure.  However, this study itself also missed an opportunity for better measurement when they estimated Resting Metabolic Rate (RMR) using the Schofield equations rather than measuring it with the Oxycon Mobile system they had – RMR is essentially what 1 MET is.  The study’s authors do disclose that they have receive funding support from Bodymedia, which Jawbone recently bought.

There is more to be sorted out in the consumer fitness/activity tracking eco-space.  I think devices and apps that produce valid and reliable data can make an impact in exercise-oncology research, particularly in the time periods surrounding diagnosis and treatment.

1. Lakoski, S.G., et al.  Midlife Cardiorespiratory Fitness, Incident Cancer, and Survival After Cancer in Men The Cooper Center Longitudinal Study.  JAMA Oncol. 2015;1(2):231-237. doi:10.1001/jamaoncol.2015.0226

2. Pollock ML, Bohannon RL, Cooper KH, et al.  A comparative analysis of four protocols for maximal treadmill stress testing. Am Heart J. 1976; 92(1):39-46.

3. Kim, Y., Welk G.J. Criterion Validity of Competing Accelerometry-based Activity Monitoring Devices. Med. Sci. Sports Exerc. 2015 Apr 23. [Epub ahead of print]

4. McMurray, R.G., et al.  Examining Variations of Resting Metabolic Rate of Adults: A Public Health Perspective. Med. Sci. Sports Exerc., Vol. 46, No. 7, pp. 1352–1358, 2014.

5. Byrne, N., et al. Metabolic equivalent: one size does not fit all. J Appl Physiol 99: 1112–1119, 2005.

6.  Kozey, S., et al.  Errors in MET Estimates of Physical Activities Using 3.5 ml·kg–1·min–1 as the Baseline Oxygen Consumption. Journal of Physical Activity and Health, 2010, 7, 508-516.

7. Wilms, B., et al.  Correction factors for the calculation of metabolic equivalents (MET) in overweight to extremely obese subjects.  International Journal of Obesity (2014) 38, 1383–1387.

8.  Hall, K., et al.  Activity-Related Energy Expenditure in Older Adults: A Call for More Research. Med Sci Sports Exerc 2014 Dec;46(12):2335-40.

9. Blair, C.K., et al.  Light-Intensity Activity Attenuates Functional Decline in Older Cancer Survivors. Med Sci Sports Exerc 2014 Jul;46(7):1375-83.

10. Herzig, K-H, et al.  Light physical activity determined by a motion sensor decreases insulin resistance, improves lipid homeostasis and reduces visceral fat in high-risk subjects: PreDiabEx study RCT..International Journal of Obesity (2014), 1–8

11. Montgomery, P.G., et al. VALIDATION OF HEART RATE MONITORBASED PREDICTIONS OF OXYGEN UPTAKE AND ENERGY EXPENDITURE. Journal of Strength and Conditioning Research 23(5)/1489–1495.

12. Lebouf, SF., et al. Earbud-based sensor for the assessment of energy expenditure, HR, and VO2max. Med Sci Sports Exerc 2014;46(5):1046-52.

13.  A systematic review of reliability and objective criterion-related validity of physical activity questionnaires. International Journal of Behavioral Nutrition and Physical Activity 2012, 9:103 pgs 1-55.

Activity trackers … beyond just us fitness geeks

walk-500-3

This video is how I see exercise data in oncology.  Of all the training I’ve done, which I recorded but which no one else did, and of all my data sitting in Garmin, Moves, RunKeeper, Moov, and MiFitLife databases, not one byte of it is in my EHR (Electronic Health Record).  However, during my stay in a hospital isolation ward for my allogeneic stem cell transplantation (donor HSCT) my bowel movements were recorded and entered into my EHR.  Exercise affects gut microbiota (bacteria) and immune function (1), and diversity of gut microbiota correlates to improved survival from a donor HSCT (2).  Did the exercise I did prior to and throughout my stem cell transplantation preserve my gut microbes, affecting my immune system, which helped me breeze through stem cell transplantation?  Who knows?  But since the data for all this exists, it sure would be nice if it were gathered together in the same place (EHR) in order for me and other patients to find out.

At home, my treadmill is Bluetooth compatible, but none of the workout miles I’ve done on it are in my EHR either.

Outside, sigh … you get the picture.  Fitbit, Nike, Jawbone, Garmin, or ‘fitness this’ and ‘fitness that’ app/device, please do not spend one more dime on another advertisement touting your latest model or bells and whistles.  Instead, hire more (or better) IT people proficient in medical coding/HIT, exercise science, and data interoperability, and free our data from your proprietary databases so that it can be used, if we agree, within EHRs for research.  Looking at a graph of the last few months of my training does not benefit others, no matter how inspiring some may think my training to be.  We are losing too many people like Laurie Becklund, and activity tracker data on us may be significant toward improving survival from cancer.  Exercise decreases cancer metastasis, in mice studies anyway (3, 4, 5).  Is the data right at our wrists for metastatic significance in humans?

ResearchKit, can data flow back into subjects’ EHRs?  Exercise researchers, how much of the study data generated from subjects goes back to them so that it can enter their EHR?  EHR vendors, do your patient portals even accommodate exercise data should it become useable?  National Coalition for Cancer Survivorship, can we improve the Journey Forward, Survivorship Care Plan tool’s small section on exercise and populate it with valid activity tracker data similarly to how it is populated with cancer registry data?

This is not rocket science, neither is it a billion dollars in new drug development that marginally improves survival for a few months, this is already here, we just have to capture it in ways that can actually be used to save lives.

There’s a lot of interest in tracking physical activity, ranging from simple weight loss tools to more high-tech gadgets for mountain climbing or ultra-endurance events.  Altitude, distance, speed, calories, heart rate, steps, type of activity, intensity, and even time spent sitting, are just some of the variables being recorded.  Smartphone ‘apps’, watches/bands, heart rate straps, pocket/clip-on devices, ear buds, and web-based diaries are able to collect these variables.  However, few of these devices, including ‘apps’, have been validated – scientifically tested for accuracy against a criterion (standard).  This is important if we want to use consumer fitness data (Patient-Generated Health Data – PGHD) for more than just personal curiosity, which typically wanes after a few months.  If you haven’t validated your device, do it.  If you fear the results, then improve your product so that it accurately records valid fitness measures.

For exercise-oncology research, and exercise research in general, in many ways PGHD from validated activity trackers can be more accurate than Patient Reported Outcomes from validated questionnaires.  Either way, data comes from patients, but some fitness trackers are as accurate as the criterion (6).  This I like because it will require other fitness trackers to improve accuracy.  Developers unwilling to validate and improve their device will be relegated to the Big Data sidelines, if they survive at all.  Regardless of how sophisticated and proprietary a devices sensors are, most end measures will be the same as from other devices – energy expenditure – kcal, estimated VO2, METs.  No longer should an app be able to use a metabolic equation inaccurately and have their data be relevant.

Validated activity trackers have the potential to expand physical activity related observational research to every Electronic Health Record (EHR) – this is a big number, over a billion, which is much larger than the fitness geek marketplace.  For small population cancer types, which get little, or no, exercise research due to their inability to recruit enough patients from single or multiple healthcare facilities, this could do wonders for statistical power.  Might we find similar benefits for exercise among other cancer types as have been found in brain, breast, colorectal, and prostate cancers?  Will we discover more information about intensity, duration, frequency, and type of exercise regarding proximity to diagnosis and treatment?

For cancer patients, having our physical activity automatically tracked, medically coded, encrypted, summarized, and made available for upload into our EHRs, this may be the least invasive thing involving our body, and with the lowest cost per survival outcome.

 

1. The microbiota: an exercise immunology perspective. Bermon, S., et al.  Exercise Immunology Review  2015;21:70-9.

2. The effects of intestinal tract bacterial diversity on mortality following allogeneic hematopoietic stem cell transplantation. Taur, Y., el al.  Blood, 14 August 2014 x Volume 124, Number 7.

3. Effects and potential mechanisms of exercise training on cancer progression: A translational perspective.  Allison S. Betoff, Mark W. Dewhirst, Lee W. Jones. Brain, Behavior, and Immunity 2013 Mar;30 Suppl:S75-87.

4. Exercise modulation of the hosttumor interaction in an orthotopic model of murine prostate cancer.  Jones, LW., et al. J Appl Physiol (1985). Jul 15, 2012; 113(2): 263–272.

5. Exercise modulation of the host-tumor interaction in an orthotopic model of murine prostate cancer.  Jones, LW., et al.  J Appl Physiol 113: 263–272, 2012.

6. Earbud-based sensor for the assessment of energy expenditure, HR, and VO2max.  Lebouf, SF., et al. Med Sci Sports Exerc 2014;46(5):1046-52.

Sweat the little things

Interior of a corridor with passenger lift

Don’t sweat the little things!

I don’t like waiting … waiting for results, waiting in lines, waiting in traffic, or waiting for elevators.  Regarding the latter, if I’m only going 1-3 flights, stairs are often quicker anyway, plus, I feel like I’m doing something pro’active’ for my health.  A typical flight of stairs might be 16-20 steps, that’s 8-10 repetitions lifting my entire body weight with each leg.  Do this a few times a day, all year-long, as a habit, and it can help maintain leg strength and muscle mass.  Consistently taking the elevator can contribute to loss of leg strength and muscle mass.  Use it or lose it – just like muscles that atrophy from lack of use while in a cast.

A hidden downside to losing muscle mass is that it can contribute to weight gain, fat weight.  Muscles are good calorie burners, when used, if not used, they atrophy.  If one continues eating what they normally do, they will gradually put on weight, because less of the calories consumed will being burned by muscle, so the unused calories get stored as fat.  Initially, this small amount of weight may hardly be noticeable, but after a number of years it can be substantial, affecting health and quality of life.  This makes climbing stairs more tiring, which can perpetuate elevator use and de-conditioning.

Major lifestyle changes, including exercising or the lack thereof, can start this way.  Don’t overlook the little things in a day – like taking the stairs or shopping –  embracing these small physical tasks can lead to change.  Shopping provides another simple opportunity to make a small change.  Park farther away from the doors rather than waiting for a spot up close, or, return your cart.  This may seem trivial, and in terms of calories burned, it may be, but it helps change the habits of our mind, habits which often prevent us from getting out the door for walks or other forms of exercise.

schnäppchenjagd

During chemotherapy, stairs served as my unofficial barometer of drug efficacy.  Prior to my cancer diagnosis I found myself getting tired after going up a single flight of stairs, my quads would burn as if I had just run up a hill.  This was a big warning sign that something was wrong with me.  Each day after starting chemo I would walk up stairs to see how my legs reacted, after a few days I notice a significant difference – my quads did not burn after getting to the top.  I knew then that the drugs were working, they were killing the cancer and I started to regain the weight I had lost from cancer related muscle wasting (cachexia).  For cancer patients with balance issues and wanting to use stairs, having someone assist you would be a good idea, certainly, use the handrail.

conceptual design representing steps to reach success

For those cancer patients accustom to exercising, yet finding themselves preparing for cancer treatment, in the midst treatment, or recovering from it, they might have to lower their exercise expectations.  I’ve talked with a number of cancer survivors frustrated about feeling lousy during workouts, or unable to complete a workout like they could before cancer.  First, I commend them for continuing to exercise throughout their cancer experience.  However, cancer treatments can have a significant effect of on the body – anemia, muscle weakness from anti-inflammatory steroids, lymphedema, surgical pain and tightness, neuropathy in the hands and feet, and the yet unknown sources of treatment related fatigue.  In spite of these treatment related obstacles, many cancer patients do exercise, and some quite a lot.  However, returning to normal gradually, or with different strategies, may be in order rather than jumping right back into their old workout routine.

Runner athlete running on escalator stairs.

One strategy I and others have found helpful, and has long been touted by former US Olympic marathoner, Jeff Galloway, is walk/run.  For me, building up to walking 4.2 miles per hour at 11% grade on my treadmill, a good workout in itself, became physically awkward, running seemed like it would be more comfortable.  However, starting out running a little bit at a time was easier than trying to cover 3 miles all at once right out of the gate.  I used walk/run, beginning with walking 100 meters, then running 100 meters.  That soon progressed to 200 meters, 400 meters, then eventually 3 miles straight, and soon I was back to my normal running routine.  Rest/exercise, coast/pedal-paddle-row, float/swim, etc., could be applied to other activities.

A number of cancer survivors have returned to the highest levels of competition as professional athletes: tennis players Ross Hutchins and Alisa Kleybanova; hockey players Mario Lemieux and Saku Koivu; major league pitchers Jon Lester and Dave Dravecky; and runner Gabe Grunewald; among many others.  The fitness demands of those sports are significant, yet their bodies recovered, and so can yours, probably not to the level of those professionals, but to a level where you are not confined to the couch.  Little things can add up!

A little exercise for me, a lot for you?

 

bikes,vintage  Cycling on twilight time

I often read stories about cancer patient’s (survivor, warrior, thriver, whatever we want to be called) physical accomplishments before, during, or after treatments – marathons, triathlons, ultras, century rides – all impressive stuff, even outside the realm of cancer.  The accomplishments seem understandable too, since exercise has been found to:

  • Improve survival in breast (1) and colorectal cancers by 50% (2).
    • Brisk walking of 2 1/2 hours per week produced the breast cancer results, but more vigorous exercise of 6 hours per week was needed for colon cancer;
  • Other researchers found moderate intensity physical activity to reduce risk of death from all causes by 60% among breast cancer patients (5);
  • and, cancer specific mortality from brain (4),andhigh grade, advanced, or fatal prostate cancers (3), were also reduced 43% and 70% respectively.
    • running 7.5 to 15.5 miles per week or walking briskly 12 to 23 miles per week for the brain cancer results, and 3 hours per week of vigorous exercise for prostate cancer.

Interestingly, more exercise did not reduce risk any further in the breast (1) or brain cancer studies.  However, for their results, the brain cancer subjects had to exceed the recommended physical activity levels (6) of 150 minutes of moderate intensity exercise per week.  Walking was also as good as running in the brain cancer study, subjects just had to walk farther.

What does this all mean for those of us affected by cancer?  Well, for the cancers mentioned above, if you’re not moving at the levels showing significance, perhaps it is time to get clearance from your physician, and start.  Practically, make exercise or physical activity a part of your weekly schedule.  It is easy to fill up your calendar with other things and people but forget to plan you into your week. Take a good look at your week, find days and times that work best to accomplish what you want, then write you into those time slots, and keep the appointment.  Book others to meet with you if needed, guilt can be the right motivator sometimes.

African American Family Parents and Children Cycling  Walking_2

Hypothetically, what if completing an Ironman Triathlon improved survival by 80%, would cancer patients, the majority of whom are sedentary, start training?  I wouldn’t be surprised if many did, determination can be great when faced with a cancer diagnosis.  However, even if willing to simply change their lifestyle, or intensely train for an Ironman, are we already hindering patients’ ability to do so by not pre-habilitating (8) them for the insult some treatments inflict on the body?  If most cancer patients do not already like to exercise, how are we ever going to convince them to start if we let their physical function decline further prior to or during the treatment process?

For those of us already in the exercise choir, and for cancer types other than those listed above, how much exercise is enough, and what may warrant caution (9) or be too much?  Unfortunately, most fitness stories remain just that, stories, unless we happen to be in a study, because, until physical activity is routinely recorded in oncology we will never know to what extent many physical accomplishments affect cancer survivorship (the ‘survivorship beginning at diagnosis’ definition).  Most of us in the cancer exercise choir, myself included, are just figuring it out as we go along, sometimes overdoing it (7), or maybe we’re not doing enough, and we share what we’ve learned with others.  Ironically, in spite of all the data we generate when training with our consumer fitness tools, there still isn’t the right statistical data to guide many of us.

senior man exercising in wellness club

Missing data …

A physical activity profile (using a short, scientifically validated, questionnaire) is not routinely recorded when extracting biopsy tissue from patients.  Is there evidence in tissue samples that could correlate physical activity to cancer treatment response rates and survival?  How are tissue samples different, if at all, between those who exercise versus those who don’t?  If different, can the differences be exploited to improve cancer treatment outcomes or to develop new drugs?  Exercise and physical activity are positively affecting survival for those cancers listed above, but how is this happening?  What are the physiological mechanisms, and are we overlooking routine biopsies as sources of evidence?  Exercise physiologists sometimes pay study volunteers and take muscle biopsy samples to find out what exercise did.  In oncology, other than pathology, how much thought is given to our biopsy samples, which patients pay for, and exorbitantly too?

I wouldn’t limit recording patients’ physical activity to biopsies only, we should be updating fitness profiles at diagnosis, first treatment, scans, and subsequent healthcare visits too.  The studies mentioned above were observational ones done over a number of years, some only assessing physical activity every two years (1,3), which doesn’t allow for teasing out information in the weeks specifically surrounding a cancer diagnosis or treatment.  Some physical activity questionnaires have gone electronic, but collecting data using paper forms, interviews, and calls to subjects is still done.  In today’s electronic world this sounds archaic, but this is how the best observational evidence has been obtained so far.Exercising on gym bikes.

Or … data to nowhere

With all the new consumer fitness products available we are still unable to get much of the data they generate into our electronic health records (EHRs).  My Garmin data, Moves data, and the information I type into my training and treatment log, all just sit there in electronic form somewhere in cyberspace.  My information cannot be pooled with the fitness data from others to search for statistical significance.  You can be sure the consumer fitness developers know a lot of things about me, but the products they have developed are generating data that goes nowhere – lots of data rather than ‘Big Data’ – my cancer and fitness story has no statistical power even though plenty of Information Technology (IT) is attached to it.

Recent announcements regarding consumer fitness and IT may change this and move us closer to continuously updated physical activity profiles by using data automatically uploaded through privacy ensured patient portals (EPIC’s ‘MyChart’ would be a good example).  Physical activity information could then be accessible when needed by clinicians from EHRs, and more importantly, tied to pathology, treatment, and other information within EHRs.  Apple’s collaboration with The Mayo Clinic, Nike, and the prominent EHR system, EPIC, appears to be headed in this direction.  However, without the broad use of internationally standardized exercise and physical activity codes for the common measures most exercise stakeholders are recording – steps, calories, heart rate, etc. – integrating the fitness data into EHRs will remain problematic.  Medicine wants valid standardized data and evidence before they will change clinical practice.  Our fitness stories, with isolated data on only one person, will not change clinical practice.

There is interest among cancer patients in allowing their data to be shared for research purposes, 87% reporting a willingness to do so (10) as long as privacy was adequately addressed.  How many of them have stories on the extreme ends of the physical activity spectrum and how is cancer survivorship going for them out there?  Fitness stories may motivate or guide others, but we also need statistical significance in order to impact clinical practice.

Swimming competition  Young Couple Jogging in Park

 

References:

1.  Holmes MD, et al., Physical activity and survival after breast cancer diagnosis. JAMA. 2005;393:2479-86.

2.  Meyerhardt JA, et al., Impact of physical activity on cancer recurrence and survival in patients with stage III colon cancer: findings from CALGB 89803.  J. Clin Oncol. 2006: 24:3535-41.

3.  Giovannucci EL, et al., A prospective study of physical activity and incident and fatal prostate cancer.  Arch. Intern. Med.  2005:165:1005-10.

4.  Williams PT, Reduced risk of brain cancer mortality from walking and running. Med. Sci. Sports Exerc. 2014 May;46(5):927-32.

5.  Irwin ML, et al., Influence of pre and postdiagnosis physical activity on mortality in breast cancer survivors: the health, eating, activity, and lifestyle study.  J. Clin. Oncol. 2008:26:3958-64.

6.  Schmitz K.H, et al., American College of Sports Medicine Roundtable on Exercise Guidelines for Cancer Survivors. Med Sci Sports Exerc. 2010 Jul;42(7):1409-26.

7.  Kano S, et al., [A case with myositis as a manifestation of chronic graft-vs-host-disease (GVHD) with severe muscle swelling developed after aggressive muscular exercise.] Rinsho Shinkeigaku. 2003 Mar;43(3):93-7.

8.  Julie K. Silver, MD and Jennifer Baima, M.D.  Cancer Prehabilitation: An opportunity to Decrease Treatment-Related Morbidity, Increase Cancer Treatment Options, and Improve Physical and Psychological Health Outcomes. Am J Phys Med Rehabil. 2013 Aug;92(8):715-27.

9.  Stan, D, et al., Pilates for Breast Cancer Survivors: Impact of Physical Parameters and Quality of Life After Mastectomy. Clinical Journal of Oncology Nursing. Volume 16, Number 2; pp:131-141.

10. Rechis, R, et al., The Promise of Electronic Health Information Exchange: A LIVESTONG Report.

 

Update:

The Future of Medicine Is in your Smartphone.  Eric J. Topol, MD.  The Wall Street Journal, 1/9/2015.

http://www.wsj.com/articles/the-future-of-medicine-is-in-your-smartphone-1420828632

Rope-a-dope and cancer – don’t punch yourself out.

 

rope_a_dope1

Boxing was a big deal when I was growing up, and the brilliance of Muhammad Ali’s boxing strategies stand out: ‘crazy man’ against Sonny Liston; and, ‘rope-a-dope’ against George Foreman are my favorites.  Getting into the heads of his formidable opponents gained Ali an edge, and the wins, but it also highlighted something important, effort is not everything, knowing when to give it all is.  If you want to win a marathon you don’t run the first mile as fast as you can, measured patience is valuable, thinking things through is important.

I think many cancer patients can learn from Ali’s strategies.  It’s often heard, and it may be the only frame of reference that newly diagnosed cancer patients have going into their first treatments, ‘I’m fighting hard against cancer’, and Jim Valvano’s ‘Don’t give up, don’t ever give up’.  Worthy mantras for sure, attitude is important.  However, Ali exploited a similar mindset in 1974 when fighting George Foreman for the heavyweight champion of the world in the famous Rumble in the Jungle in Kinshasa, Zaire.

Ali let Foreman punch him round after round, absorbing the blows while leaning back against the ropes, guarding his body and face with his arms and gloves.  The undefeated Foreman eventually grew tired, punched out, and Ali then came off the ropes and knocked  Foreman out in the eight round.  Ali strategized NOT to stand toe to toe and match brute punch with brute punch.  Instead, Ali exploited Foreman’s aggressiveness to his own advantage, until George was tired and vulnerable, then Ali was able to quickly finish him off for the heavyweight title.  As the fight was developing Ali was being criticized and questions for how he was, or was not, fighting, but he knew exactly what he was doing, and it worked perfectly.  Ali went against conventional thought and won.

Can cancer patients learn from this?  Perhaps.  Cancer patients can beat cancer but lose the battle to an infection due to their weakened physical condition.  Can exercise help, probably.  Can considering how to fight help as well?  I say yes.  I have an example from one of my own treatment experiences.

I had heard about bone pain associated with Neulasta (Pegfilgrastim), a common drug given to chemotherapy patients to boost their white blood cell counts and to help prevent infection.  After receiving my first injection of Neulasta I waited for the bone pain to start.  After a few days I didn’t have any pain, I felt lucky.  However, on the third day, while driving to complete some errands, I started having pulsing pain in my pelvis.  I thought, pelvis, a large flat bone that produces blood cells, this makes sense.  The pain would pulse stronger with each heart beat, for about 8 beats, then it would subside for about another 8 beats, giving me welcome relief from the pain before repeating this cycle.  It must have frightened other drivers to see me gripping my steering wheel with white knuckles, grimacing hard, and shouting out.  I wasn’t working on Ali’s ‘crazy man’ strategy either.  Good thing they couldn’t hear me in the car!

When I got home I called the oncology clinic to tell them about the pain and to find out what I should do.  I was told to use some Tylenol, which blunted the pain, although I could still feel the pulsing going on.  Ok, this is part of dealing with cancer and cancer treatments.  Tough it out, I’m fighting cancer I thought.  That night the pain moved from my pelvis to my sternum, another flat bone, makes sense.  I thought my femur (the head of long bones produce blood cells too) might be next.  However, the experience of the sternum pain was different.  Although the pain was blunted, I started feeling my blood pressure drop and I got some mild chills and shakes.  This concerned me since I was already laying down, and the direction my blood pressure was headed, lower, wasn’t a good direction.  I didn’t tell my wife, something common between cancer survivors and their caregivers, since she had just fallen asleep, but I was concerned about whether I would wake up if I fell asleep.

The next morning, a day ahead of schedule, I went to see my oncologist.  He listened to me give all the details about how I was doing, then he started backing to the door signaling that our session was over.  He had just put his hand on the door handle when I mentioned the chills and shakes from the night before.  “That was the most important thing you’ve said, I think you have a bone infection.”  He started me on an antibiotic infusion, and half an hour into the three-hour infusion I felt completely better.  I had been walking around with a bone infection and I had thought it was just part of the pain from the Neulasta shot.  What might have happened had he left the appointment not hearing about the chills and shakes?  The Tylenol was masking the pain and I accepted the pulsing in my bones  as part of fighting cancer.  I was rope-a-doping myself – fighting with maximal effort, being tough, accepting the pain, when I may have been on the verge of being knocked out, maybe even for good.

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So, for all you tough, stubborn, cancer fighters out there, keep it up, but also be willing to sometimes consider backing off and redirecting your efforts.  And for those of you who have been putting off getting that lump or mole checked out, or if you have not had a physical exam in years, get in there!  Don’t rope-a-dope yourself before any fighting even begins, and set aside time each week to improve your fitness, if you have to fight, it’s better to be physically ready for it.  It is no fun getting a prostate exam or colonoscopy, but dropping your drawers, bending over, and taking it up the backside can be a winning strategy.

 

Time to consider ditching the chemo recliner?

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A cancer study published earlier this year found some very interesting results regarding the blood flow of tumors at rest versus during exercise.  For some of you, it may be a surprise to learn that this had not yet been studied in animals or in humans.  For me, I have been waiting for something like this for the past 2 1/2 years, since I began looking into exercise and cancer survivor research.  In spite of all the cancer fundraising events where people exercise to raise money for cancer research, little is know about what all that exercise may be doing to tumors.

The study (only in rats) examined prostate tumor tissue at rest and during low to moderate intensity exercise.  At rest, the blood flow to prostate tumor tissue was less than that of the surrounding prostate tissue and less than that of the control animals’ prostate tissue.  However, during exercise, the prostate tumor tissue blood flow increased 200%, significantly above that of the surrounding prostate tissue or that of the control animals’ prostate tissue, both of which remained the same as at rest.

If you’ve ever had chemotherapy or accompanied someone who has, you may remember those nice, comfortable, recliners for resting in while the drugs pump into the veins.  Well, if we could extrapolate the results of this study, resting in recliners would seem to limit blood flow into tumors at the very time that we want it to be at its maximum – while the drugs are flowing in.  Now, before you get too concerned about infusion nurses yelling at chemotherapy patients to ‘push it’ for 30 more seconds on the treadmill, remember, the study used low to moderate intensity, and as I wrote previously, intensity is relative to each cancer patient’s fitness level.  For many patients, I would not be surprised if strolling around the infusion ward was low to moderate intensity exercise, and for some, maybe even near maximal intensity.  Currently, one of the best parts of chemo infusions could actually be the walking out of the infusion ward when it’s over, plus, any ‘exercise’ (shopping, walking, work/household duties) done afterwards until the chemotherapy drugs are metabolized or eliminated.

They let us walk into and out of the chemotherapy infusion wards, why not walk during infusion?  Some concerns may be over balance due to any sedatives administered as a part of the infusion process.  True, but some sedative doses can be decreased.  When I had to drive myself home after a series of infusions, they cut my Benadryl in half so that I wouldn’t be woozy for the drive home.  There must be other sedatives as well that could be similarly adjusted.

An editorial that accompanied the cancer study I cited above, mentioned how emerging evidence is ‘beginning to challenge the current perception of exercise as a “soft” intervention that “cannot hurt.” ‘  This is similar to what cardiology went through decades ago.  Then, patients were sent home to bed rest for weeks after a heart attack.  Once more research started coming in, showing that patients did better if they started exercising soon after their heart attack, cardiology started getting patients moving.  This may be where we are with cancer treatments and exercise – leaving the ‘soft’ intervention realm and moving into the “A Team’ of evidence that shows improvements in existing cancer treatments.   But we need human studies first, this is why I started WorkOut Cancer.

I hope you’ll help us to move evidence like this along into human studies.  This is not rocket science but basic physiology, much of which has been overlooked in favor of billion dollar drug development.  Fair enough, there are many effective cancer drugs, I’m not opposed to them, but can we improve the delivery of those drugs with something as simple as switching from recliners to strolling the infusion ward halls?  Furthermore, what else might we discover about these physiological mechanisms that might improve cancer treatments?  We will never know unless we do more research like this.  Please donate.

Thank you!

 

References:

Modulation of Blood Flow, Hypoxia, and Vascular Function in Orthotopic Prostate Tumors During Exercise.  McCullough, D.J.,  et al.  J Natl Cancer Inst 2014 Mar 13. [Epub ahead of print]

Therapeutic Properties of Aerobic Training After a Cancer Diagnosis: More Than a One-Trick Pony?  Lee W. Jones, Mark W. Dewhirst.   JNCI J Natl Cancer Inst (2014)dju042doi: 10.1093/jnci/dju042First published online: March 13, 2014

Chemo man brain … it ain’t pretty!

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The male brain is odd enough (I heard those amens ladies!), apply some chemotherapy to it and the results can be, well, let’s just be kind and say … interesting.  A typical generalization is that men are driven to solve problems while women are motivated by emotion.  Us guys try to fix things, that’s what we’re wired to do.  Note the word ‘try’, because we’ve been known to make things worse (I know ladies, I know).

One of my favorite stories is from the book  And In Health by Dan Shapiro, PhD.  On pages 143-144 Dan tells the story of a couple talking, then laughing, about how lucky they were when the chemo brain affected husband nearly burned down their house after forgetting he was cooking something on the stove.  The lucky part was that the overflow from the bath he forgot he was running upstairs crashed though the ceiling and put out the fire.  I laughed until I cried at that story.  Check that off the bucket list.

My story is not nearly as dramatic but is probably not uncommon for the types of distorted plans men can come up with under the influences of chemo brain.  As patients, we are given time between chemo cycles so our bodies can repair before the next toxic assault.  Well, tumors are a part of the body and they can regrow and repair between chemo cycles too, some drugs may even contribute to that process.  I wasn’t about to let that happen without the potentially ‘normalizing’ affects of exercise, which I hypothesized would influence, in my favor, any regrowth or repair that my lymphoma tumors might be trying to do.

After my chemo cycles I often had low blood pressure, which caused me to become dizzy from standing up.  A cancer specialist physical therapist told me a technique of pumping my legs before standing up to raise my blood pressure.  This helped.  However, that first day home, I was concerned that my plans for walking on the treadmill might be dismantled by my low blood pressure, so I fired up the chemo man brain for a solution.

I decided I would text my wife ‘ok’ every 5 minutes while walking on the treadmill.  If she didn’t get a text then she should call the EMTs.  Great plan I thought, some of you guys are agreeing while others are already improving on the man plan – you should have done ‘face time’ or done such and such.  The other brains, women’s, are rolling their eyes, just like my wife did at work while she and her colleagues agreed that my plan was the dumbest they had ever heard of.

The walk went well.  I actually felt better since my blood pressure increased due to the physical exertion.  Afterwards I continued to feel better than before the ‘workout’ (1.36 miles on treadmill at a max of 2.7 mph & 0% grade for 30 minutes – slowest of my life).  When my wife came home that evening she reiterated the stupidity of my plan.  “I had the front door unlocked for the paramedics” I told her.  “Well you forgot to tell me that” she replied, as if it even mattered.  “Why didn’t you just wait until I came home from work?” she asked.  “I didn’t think of that” I replied.  D’oh!  Chemo man brain.

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If you have a chemo man brain story I’d love to read it.  Post a reply!  Thanks!

References:

Therapy-Induced Acute Recruitment of Circulating Endothelial Progenitor Cells to Tumors.  Shaked, Y., et al.  Science 313, 1785 (2006): DOI10.1126/science.1127592 http://www.sciencemag.org/content/313/5794/1785.full.pdf

NORMALIZATION OF THE VASCULATURE FOR TREATMENT OF CANCER AND OTHER DISEASES.  Goel S., et al.  Physiol Rev 91: 1071–1121, 2011 doi:10.1152/physrev.00038.2010  http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3258432/pdf/nihms348021.pdf

Physical activity and tumor vessel morphology among men with prostate cancer.  Van Blarigan, E., et al.    http://mb.cision.com/Public/3069/9520261/82b38a3d9391d0bb.pdf

Exercise modulation of the host-tumor interaction in an orthotopic model of murine prostate cancer.  Jones, L.W., et al.  J Appl Physiol 113: 263–272, 2012.

And in health A Guide for Couples Facing Cancer Together.  Dan Shapiro, PhD.,  First Edition, Trumpeter Boston & London 2013,  ISBN 978-1-61180-017-3 (pbk.)

You can find out more about Ken’s treatments and training here.