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.


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



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.



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


Time to consider ditching the chemo recliner?


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!



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!


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.


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


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.

‘Bro-marrow’ lesson #1: Don’t kill the donor!


The text from the transplant coordinator read  ‘Congratulations, your brother is a match!’  Oddly, this puzzled me, which probably reflects the altered mental state a cancer diagnosis can put you in, and I ever so briefly entertained the thought that she might be joking.  Then it dawned on me, this was real, and this was great news!  Next I thought of how relieved my stressed-out wife would be and of how the coordinator must welcome sending a message like that.

My older brother was the first potential donor that we tested for my stem cell transplant.  I felt lucky, the chances of curing my complex lymphomas just went up.  Even though we are different in many ways, other than a twin, he was an excellent match.

Two weeks before the scheduled transplant he flew out to stay with us.  The flight was another source of altered mental state concern.  If he catches something from another passenger will the transplant be delayed?  Should he wear a mask?  Tell him to take hand sanitizer with him. What if the plane crashes?  Should we drive him out?  Which is safer, driving or flying?  That close to a cure, stressing the little things became a hobby if not a necessity.  However, upon his arrival I had a different plan of action, physical action.

I had just read some research finding that donors that exercised improved the stress resistance of their stem cells, and that increased the survival of the recipient by three fold.  Even though the study was in mice, my brother was going to start exercising, I’d put him on a treadmill and feed him cheese if necessary.

Luckily for him I had a Garmin GPS watch with a heart rate monitor that he could wear.  As if giving his stem cells wasn’t enough, each day he uploaded his ‘training’ into my Garmin online account, which I could access via my iPad from my hospital room on the transplant isolation ward where I was for eight days while they wiped out my bone marrow.

My altered mental state kicked into high gear a few days before transplant when my wife called saying that she was headed out to search for my brother.  He had called asking her to come get him from his walk and he seemed disoriented.  Oh no, had all the walking given him a heart attack?  What was wrong?  Was he ok?  Was he going to make it?  His stem cells, was the transplant in jeopardy?  My marrow was already being wiped out, was there a contingency plan?

Fortunately, his disorientation was only geographically related and not a medical issue.  He had started his walk late in the day and it had gotten dark which hid the landmarks that he’d recently become accustom to.  Scare over but lesson learned.  From the Garmin online data I saw that just strolling around our town’s neighborhoods for an hour a day was in his heart rate training zone.  So I asked him to just keep his walks leisurely, to enjoy himself, and to walk in the mornings!  He ended up walking 12 of the 14 days prior to donating his stem cells, more than 6 miles on one of those days.

For a brief time I’d thought that my zeal to improve the chances of a successful transplant may have killed my brother, but he was doing it all to save me.



Exercise and Hematopoietic Stem and Progenitor Cells: Protection, Quantity, and Function.  Michael De Lisio and Gianni Parise. Exerc. Sport Sci. Rev., Vol. 41, No. 2, pp. 116-122, 2013.  http://journals.lww.com/acsm-essr/Fulltext/2013/04000/Exercise_and_Hematopoietic_Stem_and_Progenitor.8.aspx

a unique record of my donor’s exercise prior to harvesting his stem cells  http://workoutcancer.org/uploads/Donor.pdf