action as you see on the screen uh... we have doctor susan malter is are chair of human oracle include hospital as well as vice chair p m in our north well hospital she's associate professor uh... at uh... donald and barbara uh... soccer school of medicine uh... we have jessica angle who is uh... our system professor of physical medicine rehab at johns hopkins university and are non-physiatrist who were happy to always join happy discussion of karen wonders who's a pg exercise physiologist uh... that she is a professor of exercise physiology at wright state university but also she is the founder and ceo of uh... her own company that she can probably talk more about before i butcher uh... any of the details but it's maple tree cancer alliance and so hopefully with her input in the discussion and info we got today uh... we can have some good it back and forth and hopefully gain some knowledge in uh... learn from each other today and so with that being said i'm gonna pass it off uh... doctor malter's probably to be taken the lead first correct all right uh... thank you for having us i think you for that great introduction doctor ship parts so wonderful to see so many familiar faces uh... these are disclosures uh... and let's get going so uh... i must admit i stole this slide from doctor katherine schmitz i'm sure you all know well and i want to start off this discussion by saying that there's been a tremendous amount of evidence showing the value and the safety of exercise uh... to cancer patients and we're gonna touch on some of that evidence in the beginning of our talk but my kind of goal with having this session is how do we move past the evidence and start implementing because to me that's really the phase that we have moved into but i also think the phase that we all struggle with um so i'm gonna hand it off to dr angle now hi thank you so much thanks for having me can you hear me okay yeah okay great so um i just was looking at some background information and um this study looks at eight randomized controlled trials of exercise training undertaking by people within 12 months of a lung resection for non-small cell lung cancer by cobble harry and this was published on june 17 2019 and in this group they found increased exercise capacity peak rate of oxygen uptake or vo2 peak and six minute walk test and um and the force of their quads as well and an improvement in dyspnea and general general health related quality of life so that's one good example if your patients or physicians you work with or other staff need some examples as well and then um this was our very famous study published one of the famous studies i should say published in november 2019 on exercise guidelines for cancer survivors and in 2010 there were guidelines published as well and at that time they said at least 150 minutes of aerobic activity each week two or more days of resistance training and daily stretching and then that was modified in 2019 by campbell's group and at that time it was changed to a moderate intensity aerobic training at least three times per week for at least 30 minutes at a clip at least 8 to 12 weeks in addition of resistance training to aerobic training at least two times per week using at least two sets of 8 to 15 reps at least 60 percent of one rep max appears to result appears to result in similar benefits and another great part of these studies and this is part of the american college of sports medicine exercise is medicine um exercise can be used for cancer treatment and prevention and it's great to start at any point in time if you haven't been exercising before now is a great time to start if you are already exercising keep going and this can be a teachable moment for folks for all adults exercise is important for cancer prevention and specifically lowers the risk of at least seven common types of cancer including breast endometrial kidney cancer bladder cancer esophageal cancer stomach cancer colon cancer and exercising during and after cancer treatment decreases fatigue anxiety and depression and those are some of the biggest symptoms we see patients with cancer no um fatigue it might even be a hundred percent of folks with cancer have that it's under diagnosed under treated under documented anxiety and depression are huge issues as well and that can affect sleep and quality of life and exercise improves physical function and quality of life does not exacerbate lymphedema which is another huge thing to tell our patients and for cancer survivors incorporating exercise to improve survival after diagnosis of breast colon and prostate cancer and probably others as well um from that roundtable discussion with Campbell's group the exercise guidelines for cancer survivors consensus statements from international multidisciplinary roundtable we found that every survivor of cancer should avoid inactivity so everything you do counts if it means parking further away taking the stairs instead of taking the elevator every little activity counts exercise can improve fatigue physical function health related quality of life anxiety and depressive symptoms and i know i have some of these things in here more than once but they're so important i had to and generally exercise is safe and well tolerated and again this is how often one should exercise for moderate intensity confined aerobic plus resistance resistance training and moderate intensity level exercise is defined by the cdc as you're able to talk to someone but not able to sing so you have enough air where you can talk a little bit but not able to sing as moderate intensity exercise um so moderate intensity combined oops sorry moderate intensity combined aerobic plus resistance training sessions perform two to three times a week or two times weekly moderate intensity resistance training may also be effective and the latter particularly in prostate cancer as well okay and the american college of sports medicine roundtable report of physical activity sedentary behavior and cancer prevention and control by patel and al um noted that we have to remember that the big elephant in the room is that cardiovascular disease is the number one cause of death in the united states if you look at everyone that's the number one cause of death um and so increased sitting time is associated with a 30 higher risk of colon cancer and exercise before diagnosis is associated with 23 lower colon cancer mortality rate however the biggest take-home is post-diagnosis physical activity appears to have the greatest influence on outcomes of cancer so it's never too late to try and it's never too late to get involved with exercise because after diagnosis is a great time it's a great teachable moment um and then this uh schmitt's paper was exercises medicine oncology engaging clinicians to help patients move through cancer showed that a lower risk of developing cancer and improve survival after diagnosis if one exercises and prostate cancer this applies even after diagnosis there's strong evidence to avoid an activity and again this is just a recommendation of how often someone should um perform moderate intensity aerobic exercise and resistance exercise um eichmeyer did this study um on the role and efficacy of exercise in persons with cancer and it was a bit ago but there were quite a few really good take-home points here that exercise can prevent cancer by helping promote a healthy body weight regulating hormones uh decreasing processes that allow for malignancy progression and promotion controlling angiogenesis via innate immune responses down regulating pro-inflammatory pathways that promote carcinogenesis increasing cell death what efficiency so cells die when they're supposed to die and don't linger on improving cell replication regulation altering tumor initiation pathways and improving reactive oxygen species mitigation um and the importance of physical exercise and cardiovascular fitness in breast cancer survivors it was the cross-sectional study women in motion um 2.0 and it was by um gil herrero um al and this was a cross-sectional study of breast cancer survivors to look at cardiovascular fitness and those with um and active uh with breast cancer and those are active versus those with a sedentary lifestyle they look at patients that have breast cancer that were sedentary those are active and they looked at a group of folks that did not have breast cancer were sedentary and those that were active and those were the four groups so two groups of active women who perform more than 150 minutes a week of physical exercise active with breast cancer and active without breast cancer and two groups of sedentary women who perform less than 90 minutes a week of physical exercise sedentary with breast cancer and sedentary without breast cancer the vo2 max was estimated by the six minute walk test speed isometric strength lower body mass maximum strength explosive strength balance and body composition were also measured anova was used to analyze group differences and post-hoc comparisons were developed with the bonferroni test and they showed okay great the results so 92 women were recruited and there were significant differences between the vo2 max between those are active with without breast cancer and sedentary i'm sorry those are active with breast cancer and sedentary breast cancer patients and there were no differences in vo2 max between the active groups but related body composition and fat mass levels were significantly lower in the active breast cancer without group and then the sedentary groups and active women with breast cancer achieve similar results to active women without breast cancer and better results than sedentary women um thank you for that um review of just some of the you know preponderance of evidence that we have supporting exercise um in cancer patients so i really like this um graphic i'm sure you all have seen it it's the american college of sports medicine recommendations again which is basically moderate aerobic exercise at least 150 to 300 minutes a week um or vigorous aerobic exercise at least 75 to 150 minutes a week as well as straight strength or resistance training two times per week and again um we don't need to go through all the things that these things helps because dr engel reviewed it already but this is definitely something that i like to review with my patients and in fact i ask them what do you think is the exercise guidelines for all americans and then what are they for cancer patients and they're always shocked to find out that they're the same next slide so um in looking in the literature what are some of the recommendations on how to stratify patients of um getting more activity or more exercise um i really uh came upon this um article and i really liked how they kind of stratify this so oncologists refer patients based on specific needs and whether they have an impairment or not and so if patients have a certain impairment um they go to a health care provider such a cancer such as cancer rehabilitation physician um or a therapist however if they don't have an impairment they go to community exercise programs and i think it's really important to have the separation between supervised and self-directed exercise for the community exercise programs so i think we are do a really good job trying to get the bucket of who goes to cancer rehab right these are the patients that may have neuropathy fatigue poor endurance or actual physical impairments i think we don't do a great job in that stratification of community exercise programs between the supervised and the self-directed next slide i get asked this question all the time about clearance for um for exercise so um the nccn guidelines don't recommend um clearance if patients um are able to walk and if they're going to be doing low low intensity aerobic exercise such as walking or cycling um as well as um flexibility i do think that it can get a little bit more complicated than that specifically for patients that have been on um anthracyclines that are being followed by cardiologists so i do think we have these buckets of patients who do benefit from some kind of clearance it's just not clear who can do that clearance so it's not clear that oncologists are really going to be able to clear patients with bone metastasis like you should do this activity but not do this activity so i've actually um in our program have developed like a bucket of patients um that i prefer the patients come to see me and i can clear them those are patients with bone metastasis um you know severe neuropathy things like that next slide so this is what we're going to be talking about today is how do you translate science into daily practice how do you shift the paradigm of we provide care that is fee-based and yet we have something that is needed that clearly adds a lot of value but cannot be paid for um in our typical way so really how do we change our paradigm of thinking and get creative next slide next slide okay so we're going to have some poll questions and i hope that these will contribute to our discussions after our talk is done so the first question is do your cancer patients receive an exercise prescription from their care team you can answer yes or no please That's an 80% answer. I'm just going to give it one more second. Okay, great. Anybody else want to weigh in? Okay. All right. Question? You guys seeing the results? Yeah. Okay, so about 53% answered yes, 47% no. So actually I find I'm really excited to hear that. We know we didn't separate whether it's physiatry or oncology, who does the prescription, and I tend to guess that it's probably physiatry so I'm happy that the patients are getting exercise prescription. Next question Megan. How many exercise prescriptions that your patients receive individualized? We get a couple more here. 77% said yes, I'm excited to see that. I'm going to guess that these are all patients that are getting a prescription by physiatry and again we can we can leave that up for discussion. Next question. Do you have a way to monitor compliance with exercise? Okay, great. So most of us do not have a way to monitor compliance, but I would really love to discuss in the discussion section of those that have said yes, what are some of the strategies that you have? Great. Next slide, Megan. So I really like this graphic that is given for oncologists to be able to refer patients to exercise. And it basically does the assess, advise and refer pathway. So assess, it's asking how many days during the past week have you performed physical activity where your heart beats faster and your breathing is harder than normal for 30 minutes or more? And how many days during the past week have you performed physical activity to increase your muscle strength? And the third question, and this is key, would this patient be safe exercising without medical supervision, i.e. walking, hiking, cycling, weightlifting? So if the question is yes to number three, the advice is a handout for exercises medicine prescription specifically developed for oncology and it's moderate intensity aerobic exercise for up to 30 minutes, three times a week and resistance training. And then refer to the available community program. If the answer to number three is no, then that patient should be following up with a rehabilitation specialist to see how they can get to the point where the answer is yes. And in my mind, when I look at this, I think of two patients. So both patients completed treatment for lung cancer and have fatigue and poor endurance, but one patient is in their 40s and was previously independent and is able to walk independently and just has some neuropathic pain from their neuropathy. The second patient is 75 and had hip replacement a year ago and still does not have a normal gait pattern. So those are the two patients that I would stratify into the exercise group and the rehabilitation group based on this recommendation. Next slide. To get a little bit more specific to what I do, every one of my patients gets this prescription. I started asking my patients what they do for fun and I really try to tease out what their favorite activity brings them joy. And then I try to tailor my recommendation based on what they do. And we discuss strategies. So if it's winter in New York, I encourage them to go to the mall. I do encourage people to get outside and breathe fresh air every day as part of their activity because I believe that also can improve mood and sleep, but nobody walks out of my office without one of these. And this is, again, something that I hand out to patients and we go over these recommendations together. Next slide. So what are the implementation issues? So one is capacity for triage and referrals. So we all know that the oncologists have a tremendous amount of demands on them. They have both clinical and regulatory and documentation demands on their time. And in this current climate of like everybody seeing more patients with less time, there is a problem with who is doing this triage and who is figuring this out, right? This is probably like a 10 minute discussion to have with a patient. At least it takes me 10 minutes to figure out where they're at. And then identification of community-based programs. So it's kind of like the onus is on the referrer to identify like potential gyms or potential Ys or potential programs in the area. Very few cancer centers have, that I'm aware of, have gyms embedded on their campus where this is a seamless process. So again, the onus is on the healthcare providers to try to figure out what exists in their community. And then of course it's cost, right? I know that for our exercise programs that we have implemented, they're all done like on a volunteer basis by our therapists and our exercise physiologists. But this is something that's a big barrier. Next slide. I wanna talk a little bit about what we do at Northwell. We have several large cancer centers. Within the cancer centers, there are some yoga, some tai chi that are done through small grants. We do have a center for wellness that is geographically about 30 minutes away from the cancer center where patients can take yoga, pilates and some exercise classes for just $5. We also have a JCC that has free exercise classes for cancer survivors that is really good, but is also about 20 minutes separated from the cancer center. And basically what happens is that every disease team wants me to help them develop exercise for their patients. And so we're kind of doing everything piecemeal and that's not exactly how I'd like it. And we don't have any real data on how many engage. That's something that I'm working on this year. Next slide. So I wanna just take you through two little programs that I've developed. I decided to embed exercise rehab program because I have kind of control over those patients as opposed to the oncology patients who may not be coming through my door. So you'll forgive some EMR specific names here. So this is a breast cancer prehab program where the surgeons refer the patients prior to surgery. They get lymphedema surveillance and are getting. And at the same time, they're enrolled into a twice weekly virtual exercise class given by one of our physical therapists. And that continues through their surgery into the post-op period. And we use the FACT-B tool to kind of monitor outcomes. Of all the things on here, which is lymphedema surveillance, visit with a physiatrist, prehab booklet that we give to patients and exercise classes that are virtual, the thing that has the least uptake is the exercise classes that are virtual. So patients will be able to go for other things. Getting compliance for those exercise classes has been really hard. Next slide. This is another program that we're doing for patients from a small grant that I got for patients going to adjuvant chemo for breast cancer. So from diagnosis, patients is going to, patient, I'm sorry, I actually flipped the two programs. So hang on one second. Okay, I'm sorry. Can you go to the previous slide? Can you go to the previous slide? Cause I mixed up the program. So this is a new adjuvant group that is referred for two times a week virtual exercise class with an exercise physiologist. And they will be undergoing that class for 12 weeks. And after that class is over, we have some graduation Peloton bikes that we got a donation. And so those patients will be going into a graduation exercise program. Next slide. So this is what I was talking about earlier for patients who are about to undergo a mastectomy and are enrolled into a prehab program that involves lymphedema surveillance and a twice weekly exercise session with physical therapy. Next slide. So I'm gonna hand it back to Dr. Engel to talk about her experience at Hopkins. Hi, so thanks. So we see patients at all stages. We see patients on the consult service, for example, while they're in the hospital, as well as in acute and patient rehab, post-acute rehab as well, and outpatient rehab. And I see patients both in Maryland and Washington DC. So the next slide, please. So for example, this is one of the hospitals that's in DC in conjunction with the hospital that's right in a suburb of DC in the National Capital Region. We have a lot of virtual cancer support programs that I'll talk about for those that are interested. And these are just a little bit of what's going on, for example, this month. So we have Reiki that some patients will engage in, and this is mostly virtual. And then there's a yoga program as well. And the yoga program was in person before COVID and has now become virtual. And that's actually very helpful for a lot of folks. They get very engaged with it. And it's through a virtual platform, like a Zoom, for example, type platform. And so that can make folks very comfortable because some of these people haven't done exercise in a long time. Sometimes people aren't comfortable with what they're wearing. They wanna know that there's an out as well, if they need to, if they're not feeling good or if something comes up or this isn't the right fit for them, that they can just exit the virtual platform or close the screen or what have you if it doesn't work for them. And this is actually yoga is quite great because it comes in three varieties. One variety is traditional yoga where folks are using a mat and you're up and down. One yoga actually is a combination in between. And the other yoga is really good for folks. And that's chair yoga. So if someone has impaired gait or impaired balance and they're not ready to do standing yoga, they can do the chair yoga. And the chair yoga is great for anyone. It's very, really helpful. It's a great starting point for folks with even very progressive disease. We just talk about different precautions that need to be used, things like spinal precautions. And so there's the mat class, which is like traditional yoga, the chair yoga, and then there's a combination of the chair and mat, which is the chair mat format that you can see here. And those are, they're quite frequent actually and at different times of day to allow for people to either do them during lunch or during the morning or in the evening. And if folks get into it and they travel to see a loved one, they can still do the yoga class. And that's been very, very helpful. And we've had a lot of people that are very interested in that. And then they tend to do some of the other mind body classes as well, such as Reiki once they learn more about the virtual classes and some of the virtual support groups as well. Can I have the next slide, please? And then one of the other options is meditation, for example, that folks will get involved with meditation. There's a talk and walk group. There's also art therapy and cancer survivorship series. The art therapy actually was so well attended and people liked it so much that they then met in person, even though it was virtual at first. There's various support groups. And then there's also Sibley, which is the Washington, D.C. hospital has senior association that works on mindfulness, outdoor walking groups. We partner with local agencies. There's been kind of a different flavor since COVID. There are silver sneaker programs at YMCAs, for example, that we encourage patients to partake in. We also have had patients that have asked about getting a trainer who is knowledgeable in patients that have cancer. And sometimes we refer them to the American College of Sports Medicine website, where you can look for a trainer in your area, wherever it may be, and look for someone who has that cancer certification. And we have, in the past, had most of these programs in person, and now they are virtual, like I said. And some of the walking groups are getting back together, but it can be very difficult sometimes when some patients were very, very, very active before they had cancer and exercise was their medicine, exercise was their therapy. And some of these folks that were doing ultramarathons and triathlons and things like that to then have that exercise taken away, and where do they find themselves now? And that's one of the challenges that we see in trying to help those folks and trying to find active hobbies and slowly ease back into things, because we have seen patients that have gone like weekend warrior style and really hit the ground running when they're a different level of physical activity. So we have to meet patients where they are. I always ask patients what their hobbies are and what they like to do for fun as well. And that actually usually puts a smile on people's faces. I also ask them if they have any pets, because sometimes people will be walking dogs. I think I have one cat walker as well, but different activities where you can get patients active are very important and meeting patients where they are and doing something that they enjoy. Next slide. Okay. All right, I think it's my turn. So I'm here to talk about the introduction to virtual exercise training. And I'm gonna talk a little bit about how we got to this point and then the feasibility and the efficacy of such a program. So historically, individualized supervised virtual exercise training was not largely used in a cancer population. And this goes back prior to the COVID pandemic. However, in March of 2020, a lot of clinically based programs were forced to decide between closing their doors or pivoting to a virtual model. And this was not expected to be an easy transition, especially when you take into consideration the age and the health status of that patient population. So our particular exercise program did make that decision to pivot to a virtual model and see what happened. We collected data along the way. So I'm gonna be presenting a lot of that data here today. This was published in Current Sports Medicine Reports, which is a journal of the American College of Sports Medicine in May of last year. And then since then we've widely adopted virtual exercise training in our clinical partnerships. So my focus today is going to center on the feasibility, the safety and the efficacy of a supervised, individualized virtual exercise training program for patients. Next slide. So whenever we talk about implementations, I think there's a number of things that we can take into consideration. So the first thing I wanna talk about is the staff expectations. And so it is expected that the exercise oncology instructor be certified and understand how to use the technology so that they can explain and troubleshoot for their patients if needed. I believe also that staff should ensure patient safety by observing the patient's training environment during the session. So we wanna make sure that we're avoiding exercising where it might be slippery or where objects might get in the way of the full range of motion for the patients. Also, we insist that there not be more than two individuals on the exercise training call and this is to protect the patient's safety and their privacy as well. So we want the patient's camera to be on and in a position where we can fully see that patient's full range of motion. Next slide. In terms of a fitness assessment, this was something that we really had to work through because traditionally, of course, we had done a fitness assessment as soon as a patient was referred to us so that we could identify strengths and weaknesses and make the exercise prescription accordingly. So when you're doing a fitness assessment virtually, you have to take into consideration what kind of equipment, if any, does that patient have available to them. And so we have a very basic fitness assessment that we can do virtually that really does not require any equipment other than a chair for an individual to go through. And in order to do that, we look at the get-up-and-go test, and then we do the 30-second arm curl. If they have a soup can or something that they can use, this is going to measure the upper body endurance. We look at the chair sit and reach to look at lower body flexibility. And then we have a series of range-of-motion tests that we can look at to examine both upper and lower body range of motion. And then finally, we have a four-stage balance test that doesn't require any equipment and can safely assess an individual's balance. Next slide. So the overall goal of the exercise program is to minimize the general deconditioning and treatment toxicities that often accompany cancer treatment. So as has been mentioned here today, we utilize the American College of Sports Medicine guidelines, and we make sure that that program follow a slow progression that's going to demonstrate adaptability to changes in that patient's health status and keeping in mind that their health status is going to change from day to day depending on their treatments. You know, most research does support that individuals who are undergoing cancer treatment would benefit from a low-to-moderate intensity program that incorporates a full-body workout. So we want to make sure we're including aerobic strength and flexibility training. For these virtual home sessions, the program can be adapted depending on what kind of equipment that that patient has available in their home. And when necessary, we use alternatives such as soup cans or milk jugs. And I'm going to highlight a little bit later that that is actually very beneficial in a patient, which kind of goes against what you think. So I'll talk about that in a minute. But next slide. So the feasibility of this. You know, at the time that we pivoted to virtual exercise training, we had a total of 491 patients who were actively engaged in our exercise program. And these patients ranged in age from 14 years to 83 years old, average age being 60. And so the initial barriers to a virtual exercise program that we predicted focused around technology uses, both in terms of the wireless connectivity, the comfort using technology, camera placement, and even access to the Internet. I even remember doing a Facebook Live trying to teach people how to use Zoom because it was such a foreign concept to us back then. So there have been previous studies that have looked at home-based exercise programs and they have found them to be feasible in chronic disease populations and yielding positive results in physical activity participation in aerobic fitness. So we had reason to be optimistic. To examine the feasibility of our virtual program, we utilized an independent third party to gain perspective on the patient experience via a phone interview. Of those surveyed, it was discovered that 46% of patients used their cell phone for the virtual exercise session, 50% used a laptop or tablet, and 4% used a desktop computer. 67% of the patients used Zoom or Skype for their exercise sessions, while 21% used FaceTime. And there was a small minority, around 12% of patients, who did not feel comfortable using either one of those options, so they opted for a phone call. And we just did the best we could with those. In the 12 weeks of exercise training, 30% of patients reported no challenges to the virtual exercise training. A remaining 20.4% reported minor technological issues and another 18% cited the challenge of needing to just get used to virtual instruction. Overall, though, we reported an adherence rate of 84%, which we were very pleased with. This is slightly lower than our in-person adherence rates, which are around 90%, but still under the national averages, and so we were pleased with those. You can go to the next slide. In terms of safety, no adverse events were reported during the course of our study and still, to this day, have not been reported since the widespread adoption of the supervised individualized exercise training virtually. As a standard of practice in all of our facilities, whether the individual is in person or virtual, we do use this triage tool that was developed by a physical therapist named Dr. Kelly Covington-Wood. She's a researcher in this space, and this triage tool assesses patient readiness to participate in an exercise program. And it identifies the need for more skilled service line for the patients, if necessary. So, therefore, all of our patients were determined to be able to safely participate in a supervised virtual exercise program prior to the start of the program. Next slide. In terms of efficacy, surprisingly, 67% of our patients reported that they felt that their exercise intensity was the same as it was in person, with 12% saying it felt like a higher intensity. Data on our supervised virtual program revealed significant improvements in fitness parameters. Specifically, you can see here that patients reported a 15% improvement in muscular endurance, an 18% improvement in cardiovascular endurance, sorry, 18% improvement in muscular endurance, and a 31% improvement in flexibility. Physiologically and psychologically, patients experienced a 48% reduction in fatigue and a 32% increase in quality of life. Next slide. Oh, and then these are the fatigue and quality of life slides. Next slide. And I reported this data earlier, but just the devices that were used for the virtual exercise training, you can see most of the individuals that we used utilized a cell phone and it was propped up in such a way that we could see them. And then this is the breakdown of the remainder of the devices. And the delivery method of the exercise program. Next slide. And the intensity level comparison. Next slide. Okay, so in closing, I did want to highlight this story because I was someone who heard the phrase, oh, well, if you don't have any exercise equipment, just use a soup can. And I'll admit that there was a part of me that thought, oh, like how effective can that actually be? And so I wanted to share this patient with you. This is Abby. She's one of the patients we serve. She actually lives in Berkeley, California. She lives alone and has a foot injury that prevents her from doing any kind of weight bearing activity on her legs. So she did not have any type of exercise equipment in her home and she did not have the means to purchase any new equipment. So she used soup cans during her virtual exercise sessions, as you can see here. And what was really remarkable was that after 12 weeks, we reassessed her and put her through that fitness assessment again. And we found a 70% improvement in her right arm muscular endurance and a 94% improvement in her left arm just by using soup cans for her exercise training. And so for me, in closing, it was Abby's story that really has made me a believer in virtual exercise programming and really makes me want to advocate for its adoption on a more broad scale. So thank you. And these are just some more professional organizations that have endorsed exercise oncology, most notably ASCO released guidelines in May of this year. And those guidelines were pretty strong stating that all cancer patients should be involved in an exercise program. So I feel like we are moving in the right direction to gain momentum for this important field. And these are my works cited. Well, thank you. That was a great and very informative talk throughout. What I want to do is open up for the audience for questions. I know we got a decent crowd here. Whether you guys want to put a question in the chat or feel free to unmute and ask any questions before we kind of jump in. I know we definitely have some people that have been engaged in this process. So hopefully we hear from them too, whether it's a comment versus a question. I'll give a moment to everyone before I start asking questions. There's some Dr. Smith. How many people participate in the virtual yoga or other classes? That's a great question. I did not get the numbers on that. I apologize. I have to ask. I know it does vary, though. And I was just thinking that would be a good thing to look at how many people I refer and they send the information to. But I don't think that they're huge. I don't think it's, you know, I think it's probably less than a third, maybe less than even a quarter of who's referred ends up doing it. But the people that do it, do it and they love it. They stick to it. And sometimes that's a gateway for them. So I think that's a good follow up from Philip Chang has a follow up where I think this is a question that we all battle of great stuff. Where does funding for most of these programs come from? And is it sustainable? And I know we've kind of briefly touched on this, but I think it's a good question. So I think that's a good follow up from Philip Chang has a follow up where I think this is a question that we all battle of great stuff. Where does funding for most of these programs come from? And is it sustainable? And I know we've kind of briefly chatted at varying forums about I think there's the cost to the patient. And I think, Karen, you can probably even discuss a little bit of, you know, just funding for people's time. Right. And so, you know, depending on how we have participation and obviously you want one on one and other things. A lot of these patients in our patient population are not having free flow cash. So I think that's an important part of we talk about idealized interventions versus the reality that we end up facing of what we can get into people. I think that may be a good one from all three of our speakers. So I can address what we've been able to do. So generally what we do whenever we partner with a new clinical site is we work with them, either the hospital foundation or a private foundation or a donor or some kind of, you know, funding like that. And we're able to get funding to start what we call is a pilot program. And oftentimes that's just a couple of days per week. We limit the number of sessions and the number of appointments per week that we're able to do. And that allows us to build out a pretty reasonable budget initially just to build out the program, get some testimonials, get the patients to love it and then the doctors to champion for it. And then from there, we're able usually to work with the cancer center to get funding internally out of their overhead budget. And we've been able to do that pretty successfully so that we don't have to charge patients for the services that we provide because we do understand the financial constraints with cancer and, you know, the whole nine yards. So that ultimately is our goal. And it has been pretty successful for us. We've been in operation for 11 years and serve a number, you know, thousands of patients every year. So we've been able to successfully do that. To clarify a little bit, Karen, so you're basically saying the cancer center kind of, once you kind of get going, the cancer center has maintained that funding, not billable, not anything. They're just kind of supporting this as an adjunct service for their patients, correct? Yes. So in those situations where we've been able to successfully transition from the foundation support to overhead budget, generally that comes out of radiation oncology. Apparently there's some wiggle room there. We're also a lot of times able to integrate with a rehab service team. And sometimes there's margin in that budget as well because they, you know, their services are billable. Ours are not. Exercise oncology, exercise physiology is not billable yet. That is something that we are actively working towards. I'm optimistic we'll get there in the next five to seven years. But it is an uphill climb. So I'd like to thank Pam Goetz who organizes everything and also answered my text message at almost eight o'clock at night because I didn't know until now. It's from a grateful individual donor who was helped so much by yoga during her treatment and unfortunately passed away. And she had funds and gave them to start these virtual classes for integrative medicine and integrative classes. And I think for us also, the integrative classes, the yoga, the exercise, as well as I know the JCCC classes, they all come from philanthropy. And to answer your question, Brian, or I'm sorry, it's not always sustainable. So I think that's where the paradigm shift has to happen, right? Like how do we incorporate exercise and deliver it to every patient as part of the standard of care so we're not kind of coming up for these piecemeal exercise programs? I'd love to also hear from the audience your experience with exercise and implementation. How do you monitor compliance? We'd love to hear your experiences. Hey, Susan, it's Brian Perkey here. So I don't use this as much here where I'm at in San Antonio, but I know we did use it a little bit in fellowship as not a direct monitor of compliance, but kind of a broad, general monitoring of compliance as we looked at body composition measurements. So those patients that we would put on aerobic and that was in the prehab setting, but we would give them this exercise prescription, told them aerobic activity they needed to do, resistance exercises to do, give them handouts and sheets to perform on their own and kind of trust. But then when they would come back, we could kind of distinguish, at least clinically, those who would more likely participate in the program than those that didn't by looking at the body composition measurements. If someone's body fat percentage went up after eight weeks of exercise, then that's suggested that they weren't as participatory versus the individuals whose fat-free mass goes up by five to 8%. And we were able to corroborate that, at least with MD Anderson. They were able to corroborate it because they had a nurse who is dedicated, who would contact all of the prehab patients every two weeks to check in on them. And she had her own ways of confirming adherence to the exercise program. So that's how I've seen it done before. Actually, I think it's a great idea. I just wanna read Dr. Gerber's comments. We need to use functional outcomes to justify the value of exercise and that most studies care about mortality, VO2 or strength, and CMS might be more likely to reimburse if you were to add functional outcomes to demonstrate participation. I completely agree. I guess it's just a question of like, who is doing those screening function, right? So like, we would be great at that. And I think we could demonstrate that value, but do we have the bandwidth to have every cancer patients come in through our doors? I think that makes it more challenging. Well, there are several people on this call. Sean Smith is one, Mary Vargo is another, Sam is another. We batted this concern around quite a bit to decide what should we use as outcome measures. I won't use the term universal, but possibly consensus building. And that was geared towards determining function, not only range of motion, although the functional measures included ROM, it included, shall we say functional stamina, I hate to use that term, but you know what I mean, for dressing, for out of house activities, et cetera. I think the trend is definitely in that direction. Mary Vargo and I have been looking at outcomes from rehab interventions for non-small cell cancer patients. And again, the universal outcome measure is a six minute walk distance. And yet we all know that that is perhaps a minimal assessment of outcome that we would like to see in our lung cancer patients. So I am urging people to think about promise or I have no stock in the company, please do not misunderstand me, but to open our minds a bit, since we frequently measure VO2, we frequently measure some kind of objective metric, body mass index or free fat mass or whatever, all important. But the bottom line is really the functionally based outcomes. And there's very little in the literature that shows what I think most people on this call would like to see as outcomes from our very carefully prescribed, adhered to and supervised interventions. And that is a gap. Thank you. Sean, Mary, I know you guys got called out a little bit by Dr. Gerber, do you guys wanna have anything to add? Sorry guys, but we all need to stick together here. I agree Lynn, I've done a lot of talking. I wanna see if Sean or Mary wanted to add to that given your call. I mean, an exclamation point on all of that. The things I've been thinking about as far as some of the topics today were the monitoring of compliance. Like we do spend time talking about exercise and optimizing function and just finding the time to give that exercise prescription or what even is an exercise prescription? Is it that piece of paper or is it taking the time to talk about it and put something on their visit summary but really tracking that systematically is a challenge and another role like Phil Chang and I and others with telemedicine. So the whole virtual aspect is really interesting and there's a lot of room for it to be optimized on that end. The carving out time to do the prescription is such a tough one. We talk about it when we can but there's so much other complexity. Being systematic is difficult. The discussion about the functional outcomes is so great. We have such limited time and we can't do six minute walk tests obviously but what can we do in the limited time we have? So I think a lot of us are doing the new PROMIS tool. I certainly am but in terms of some of these physical measures I thought that was a great discussion. I wasn't familiar with the 30 second arm curl. So, I mean, there's some great options there. It'd be great to kind of consolidate around, what do we agree are useful functions to be assessing and I've talked too long. Hi, I want to just jump in. This is Adrian Christian. I'm from Miami Cancer Institute, Miami and I love the conversation. I appreciate very much everyone's thought on this. What we've been doing is collecting the PROMIS tool in our clinic as a vital sign that we use as a discussion point with the patients from one visit to the next and also taking that information in the aggregate and having that discussion with our medical oncology surgical colleagues and different tumor boards to illustrate how the physical function in addition to the other metrics can be used as a meaningful way to assess for function in patients. And we've actually started to correlate this now with mortality and with hospitalizations to demonstrate that if someone has a low PROMIS scores on physical function and fatigue that can correlate with hospitalizations and mortality and other metrics that we're using in addition to the physical stuff like the time up and go test, the sit to stand and so forth. And I found that actually by using this tool it's easy for patients to wrap their head around the fact that they're filling out this form on physical function how we could use that before and after an exercise intervention or a rehab prescription to show them how it could help them. And then using the aggregate at the tumor boards to illustrate this to their physicians as well. So it's just one of the things that we're doing at our center. Adrian, that sounds great. Can I pick your brain real quick for the group? How have you have this integrated like the PROMIS? You mentioned the patient's filling it out. Is it through the EMR? Do the patients get it through their portal? Are you giving paper and then it's getting kind of scanned in what's the process at Miami? We actually have them fill out the forms and with our medical assistance they provide them the forms, they fill it out then they get scanned to the EMR itself. We've created with our IT department a power form it's called where our medical assistant would enter the PROMIS scores into the EMR system. And then the same way that the oncologist would track let's say temperature or white blood cell count we track the scores on the PROMIS as well as other metrics from one visit to the next. And if patient comes in for five visits in a year or two years, we could track that over time and we could see the variability in their physical function score, their fatigue score and that becomes a conversation piece. So it's integrated into our EMR system right now by a scan but also by a power form created by our IT department. And that's very simple to use actually. It's a very easy tool to use for medical assistance to enter that information with a power form in the EMR system itself. It takes only a few seconds once the score is collected to enter it. And then it becomes part of the patient's actual EMR note. So it carries through whatever the patient sees on the provider, they have access to that data as part of that consultation that we provide to them for the patients. Can I ask which EMR you're using? We use Cerner. Yeah, no, I think that sounds really great. And I think something that's very needed and I'm glad that you're kind of showing that it's feasible. I hope you publish your data, Adrienne just so that we could disseminate it. We have a question from Dr. Davidoff asking the specific role of a physiatrist in the exercise oncology clinical pathway and whether therapy should be prescribed by physiatry or therapy. I mean, obviously I think we're all biased and would love to have a seat at the table in that exercise prescription. And I do think that all cancer rehabilitation physicians already are prescribing exercise. I just think that like, ultimately there are not enough of us doing this to have every cancer patients have a prescription. So I think we need to be the leaders of this movement to kind of set the guidelines of like, how do you give every patient a prescription? How do you stratify that? So I think we need to have a seat at that table. That's my answer. There's a lot of research coming out now about trying to generate an algorithm. And it's like, maybe other people filled out like the Delphi study for one of them that's gone around. And I think you're right, Susan, that like, we have to evaluate the challenging ones, right? Like you did, like people with bone meds and stuff like that, right? But I do think that like, as a field, we need to push our way in to be at the table of making those decisions, you know? So I think that sometimes can be a challenge. Hey, this is Obata, I'm over at Rush in Chicago. I actually had a question for you guys. Do you have any groups that you feel like are overlapping or good collaborators with you at your institution? I know for me, I just started and we have like a frailty clinic that they're modeling after the University of Chicago who initially started it. So it's for patients above 65 and a geriatrician heads it, but they're really embedded with the bone marrow transplant group. So we're kind of working from that angle. And then as I met with different disease specialties, I've noticed they've had their own PTs or OTs at times within clinic, but trying to find a way of kind of how to work and with that, would love to hear your guys' experience. I know that on my end, I have worked the most with surgeons. I find that surgeons really want their patients to have exercise, especially like GI lung surgeons, because there's just so much data on the efficacy of exercise. So I find that I have probably the most buy-in from them. I have seen the same, is that surgeons seem to be the first to endorse and champion for such a program. I would say he-monks would probably be second. And then usually the radiation oncologists are sometimes a group that we have to do a little bit more work to persuade, but that's just been my experience. I'm seeing a lot from definitely surgeons, but also radiation oncology from the prostate cancer side of things. As well as the prostate oncologist, because of the injury deprivation therapy and just the side effects that that has and how it affects someone's body composition and just everything, how athletic they are, their demeanor, their way they see themselves. And then also a lot of the oncologists that do breast and female malignancies is specifically on the survivorship side. So I've seen a lot that see patients on the survivorship side. I would highlight that, Dr. Engel. I think one of the pieces, the oncologists are the medical personnel that tend to see patients on the longer term end and have that follow-up. And so whether it is a physician who's involved in survivorship, it may not be the survivorship clinic or other people. Those are the people probably, because they actually pay attention to like the post-treatment or those longer term effects versus just what's happened acutely. It looks like Jessica has her hand up. So I noticed all your Jessica. Good job, Sam. Hi, everyone. For those that don't know me, I'm Jessica Chang. I just started at City of Hope in Orange County as the first physiatrist in their new startup within a startup. And so I actually have a little bit of background and so I actually have probably a very unique problem where every single person is super interested in working with me and eager to refer even every patient if I asked for it. And so my question to the group is actually like which population do you feel like is highest yield? And right now it's an outpatient surgical center, so relatively healthier patients with a breast team, a lung team, a huge GYN, GU team mostly. You know, in Miami, I found actually that the best population to start a program with, because we had the similar problem that you're facing now a few years ago, was the breast cancer DMT. And the breast cancer team, once you adopt or they adopt you in that program and become part of their team, that includes the radiation oncologist, the surgeons, the medical oncologists, and you demonstrate the benefits that you can provide to their patients, especially the ones with shoulder dysfunction. It quickly spread the word around the entire institute that you have something of value to add to a patient's care. So by integrating with that group early and the leaders of those groups and the breast cancer population, and GYN too, but breast cancer especially, was particularly useful in our case. There was recently a study that came out that looked at the incidence of falls in patients with breast cancer, and they found a higher correlation with older age and BMI. So I don't know if there's a way to tease that out or to jump off that point, for example, if breast cancer is seeing tens of thousands of people each month or something crazy. And I could try to get that for you if you're interested. We did a study, if I could just mention real quick, on early stage breast cancer and whenever we stratified according to comorbidities. And I know you said this is more of a healthier population, but in terms of ROI, we found that individuals with two or more comorbidities that had early stage breast cancer had the largest amount of cost savings with ED visits and length of stay and those sort of things. So if they're interested in ROI, that's usually what I point them to is the ones with the two or more comorbidities. Well, it looks like we went over time. Not surprisingly, good engagement from the group. I'm sure when we get in person or have more of these discussions, this will continue. So I appreciate all our speakers, Dr. Maltzer, Dr. Engel, Dr. Wanders. Appreciate your time. Appreciate everyone for participating. Hope to see some people, most people in Baltimore. And if you're not, we'll hopefully connect soon and then soon after Baltimore, we'll have more of these virtual sessions as we continue to connect throughout the year. Thank you, everybody. Have a good evening.

exercise programs

cancer patients

quality of life

symptoms reduction

virtual exercise programs

COVID-19 pandemic

funding

collaboration

physiatrists

standard of care