Hello, everyone. My name is Susan Maltzer, and I'm really excited to have you with us for this session, Exercises Medicine, Breaking the Barriers for Cancer Survivors. I'm so excited to introduce my fellow co-speakers who I've known for many years and worked together in the exciting field of cancer rehab. Dr. Sokoloff is an associate professor at the NYU Robert Grossman School of Medicine and the Director of Oncology Rehab, and has done so much work on exercise and cancer rehabilitation. Dr. Diana Molinares is the assistant professor at the University of Miami and the Director of Cancer Rehabilitation, as well as a Fellowship Director of Cancer Rehabilitation. And Dr. Jennifer Behma, who is assistant professor at the University of Massachusetts, where she is a pre-rehabilitation guru. And if you haven't heard her rap, you're missing out. So I'm really excited to kick this off and talk about why breaking the barriers to cancer exercise is so important. We all know the benefits, and it is up to us as physiatrists to help our patients break those barriers. So to kick it off, it will be Dr. Sokoloff. All right. Thank you very much, Susan. It is an honor to be with you all here today, and certainly with my esteemed colleagues. What I'd like to do in my brief talk today is I'd like to explain how we can use, as rehab professionals, we can use exercise, generic exercise, aerobic training, and resistance training as a therapeutic tool in the rehabilitation of our patients. I'll summarize some of the work that we've been doing with the ACSM Roundtable on exercise and cancer. I'd like to also describe a movement that I've been involved with under ACSM Exercises Medicine Initiative, Moving Through Cancer Initiative. So all of us attending this talk, we deal with, in our daily practices, physical impairment. We are experts in diagnosing impairment, and we, therefore, then treat impairment. So things that are maybe obvious to us is impairment, loss of body, limb, systemic function. But there's some things that are maybe not as clear. So what is under the surface? And we know that in most people living with and beyond cancer, we have a diminished VO2max, or overall cardiometabolic fitness. And that's not always apparent, but we do know that almost up to 90% or even more of patients undergoing systemic treatment, chemotherapy, immunotherapy, radiation treatment, will have a decrease in overall physical fitness, cardiometabolic fitness, or VO2max. Muscle wasting often being very common, and certainly fatigue being extremely common, almost ubiquitous in the population. At some point or another, patients are going to develop cancer-related fatigue or cancer treatment-related fatigue. We just overall see a decline in function. So exercise, as we all know by now, that exercise is actually a medicine and should be used in our repertoire of rehabilitation interventions. We know that it improves quality of life in cancer, survivors, or people living with and beyond cancer. It actually improves physical function. It can actually be used to actually alter the course of the disease in many types of cancers. It can actually improve survival. It reduces the risk of recurrence and mortality. So here, what's interesting is that as physiatrists, we actually have a role to play in the actual disease course. And I find that really rewarding and unique to what we do in oncological rehabilitation. So we can actually alter the disease course by what we do in our field. And probably all familiar with the work of the ACSM Roundtable on Exercise and Cancer. The first roundtable met in 2009. Guidelines came out in 2010 on how we should be prescribing exercise for people living with and beyond cancer. And since that time, the amount of randomized control data from the time of the initial meeting up until 2018, when the roundtable actually had to reconvene because there was so much more data, almost 300% increase in the amount of data, robust level one evidence, randomized control trial data. We had to reconvene the roundtable and many of us in the field were honored to be a part of this initiative. And it was representatives from over 20 different organizations, people from around the world, experts in their field of rehabilitation, exercise physiology, oncology. We reviewed the data and to update the guidelines. And essentially to explain the role of exercise in the prevention of the disease itself, of cancer, and the efficacy of exercise to help improve cancer-related health outcomes. And also how, most importantly, how do we take all this robust evidence and implement it into clinical practice? So essentially, what did we determine from that roundtable? And we've published on this three white papers, two came out in the ACSM journal, and one came out in the journal CA about a year ago. Essentially, in a nutshell, that we now know that exercise actually can help prevent the development of seven different types of cancers. It actually prevents specific mortality for breast, prostate, and colon cancer, whether you start exercising before or even after you have a diagnosis can actually prevent mortality for these types of cancers. However, probably most importantly, and what has never really been looked at before is that there seems to be a dose, a minimum effective dose. When we went back and we looked at the new data that had come out since the initial roundtable, we found out that actually only three times a week of moderate intensity aerobic exercise combined with resistance, with or without resistance, but combined with resistance can actually improve cancer-related health outcomes, such as fatigue, anxiety, depression, physical function, quality of life, sleep, lymphedema, and bone health. However, publications really are not enough. We know the why. We know that this works. We know that exercise is a medicine. Now we need to focus on the how. We need to know how we're going to implement this into practice. And just a key point here is that when we looked at aerobic and resistance training, we found that by combining the two modalities, we actually were able to capture actually more improved cancer-related health outcomes, as you can see in this slide here. So again, we know why. We know the evidence is strong. Now we have to shift the paradigm and be able to implement this into our daily practices. So what we're asking for is a call to action. This has to be done through a very effective, controlled assessment process. We need to be able to have a process in place where patients can be assessed, and then, of course, triage to the appropriate exercise modalities, specific personalized prescriptions, and appropriate programs. So in our third paper, we talked about just this very fact, is that we are asking for a call to action, assess, and advise, and refer approach, just like the Exercises Medicine Initiative. So we're asking our patients, we're assessing them, where they're at. Are they actually meeting the guidelines? So we're asking them, how many times a week do they actually engage in physical activity where their heart beats faster and their breathing rate is increased for at least 30 minutes or more? And we're also asking them, how many times a week are they doing exercise to improve strength? And if we find that they're actually not meeting those guidelines, then we discuss, we actually explain to them what they are. So the minimum effective dose, three times a week of 30 minutes of moderate aerobic intensity combined with two days a week of total body strength training, essentially, is the minimum effective dose to help improve cancer-related outcomes. Then we triage them. We assess where they are. Are they ready to exercise? Do they have a place to exercise? Do they know how to exercise? If not, then we can triage them and refer them to the appropriate setting. Do they have a physical impairment that needs to be addressed before they exercise? Is it safe for them to exercise? And so forth and so on. So on this slide, you can see on the left, somebody who would be more complex, who may have a more specific type of physical impairment. Let's use an example, post-myasectomy pain syndrome, or shoulder impairment, for example, in a breast cancer patient, or radiation-induced fibrosis, spinal accessory neuropathy in a head and neck cancer patient. They may require a more specific impairment-driven program combined with a generic exercise program before they can really fully get onto an effective exercise program to help improve their quality of life and improve their survival. Someone who is not as complex, on the right side of the slide, may be triaged to a supervised program or an independent exercise program. We wrote about this in the June edition of Cancer that was this year. A group of colleagues, myself from ACRM, APTA, and American Cancer Society, developed a triage model. We came up with five different categories. Cardiometabolic, so we would assess patients for cardiometabolic risk factors, oncologic risk factors, peripheral neuropathy, spine or bony metastases, aging risk factors, any comorbidities associated with aging, osteoporosis, osteopenia, frailty, muscle wasting, and so forth, other comorbid conditions. Behavioral category is a barrier. What's the patient's motivation? What has been the patient's exercise habit thus far? And then, of course, and then the final category was environmental. Is it safe for them to go exercise in the community? Do they have access to services and so forth? Do they have access to a place to exercise? Can they exercise in their home, for example? After we identified those five major categories as potential barriers to exercise, we came up with a triage system. So again, assess, right? Assess, are they meeting the guidelines? Are they actually getting the minimum effective dose of exercise? If not, then we go through the decision tree here, the algorithm, as you can see here on the slide. We assess them for cardiometabolic risk factors, behavioral, and so forth and so on. And we can categorize them further into different complexity levels. So high complex patient, for example, would be a patient who may have underlying cardiometabolic risk factors. They haven't exercised before in the past, but they're motivated to do so now. They may actually have some underlying physical impairment that needs to be addressed. That would be your highest complex. And then we would establish who would be the proper personnel, proper person for that patient to see in order for them to guide them or develop an exercise program, probably would be a physiatrist in this case. And where, what type of setting would probably be more in a more medicalized medical setting, outpatient rehab setting, for example, or in some cases, even an inpatient rehab setting. So that would be your highest complex. And you would go down to the opposite end of the spectrum where the patient would be independent. They have no apparent physical impairments. They have had exercise in the past. Maybe they stopped exercising through their cancer treatment, but now are motivated to do so because they are aware of the evidence that supports it, because they've seen someone like you who has gone to this talk and you now are aware that it is medicine that can actually alter the course of the disease. Someone like that who would be more independent could probably be started on an independent program. Now we do know that supervised people who do exercise under supervision tend to adhere to exercise better. So whenever possible, we do recommend that you try to engage your patients in a supervised setting, but that's not always feasible for a lot of people. Finally, I just want to end with talking about the Moving Through Cancer Initiative. Again, this is a global health initiative sponsored by the American College of Sports Medicine. It's under the subsidiary of the Exercises Medicine Initiative. It's led by Dr. Katie Schmitz from Penn State. I feel fortunate to be involved with this initiative as an executive committee member. And what we're trying to do is really shift this paradigm and really try to implement globally a way for clinicians to very easily and safely prescribe exercise for their patients. We have a website. It's under the Exercises Medicine website. You will go to that website. You will find the Moving Through Cancer link. And on there, you'll find all the white papers from the ACSM Roundtable. And you'll find this prescription here, a very easy to implement Monday morning fit prescription for your cancer patients. So we encourage you all to look at that and utilize that and be on the lookout for more planning through the Moving Through Cancer Initiative. I'm going to hand it over to Dr. Molinares. Thank you very much for your attention. Thank you, Dr. Sokolov, and thanks for the initiative. It has been a game changer for us trying to implement exercise in our cancer rehab practices. So hello, everybody. I'm Diana Molinares. I'm going to talk about the impact of exercise in cancer-related fatigue and health-related quality of life and mental health. So I have no disclosures. And I practice in the outpatient and the inpatient setting. And in both settings, one of the most common complaints or concerns that the patients have is that they don't have enough energy to participate and to do their activities of daily living. They always say, doctor, I really want to be active and get out of the couch, but I can't right now because I'm so tired all the time, especially when I get chemo. And this talk reminds me of a lot of my patients, but specifically to this 65-year-old female patient with ovarian cancer, who right before the diagnosis was working as an Elvis impersonator. And she was out there performing every night with a lot of energy, and now she couldn't even get out of the couch. So her oncologist called me and asked me, hey, what can we do? Because she's all the time in bed. She has undergone neoadjuvant chemo, adjuvant chemo, large surgery, and now she was in immunotherapy with a large pleural effusion and metastatic cancer. So that's when we started talking to her about cancer-related fatigue. And it is a little counterintuitive sometimes when we want to explain it to the patients because they're like, doctor, I haven't done much, but I'm so tired. And it's true. Cancer-related fatigue is not proportionate to the recent level of activity and interferes with the functioning of the patient. But it's related to distress and a subjective sense of physical and emotional and cognitive tiredness. So it's not just the physical tiredness, but they cannot participate. And sometimes this condition goes underdiagnosed and a lot of times because the patients don't report it and they are so focused on the chemo and on the treatment that they're undergoing that they cannot put this on the back of their mind. However, some studies in the literature have reported incidents of like 80% in patients that are undergoing chemo radiation, 70% patients with metastatic disease, but even patients that have completed treatment and that are under admission at that point have an incidence of cancer-related fatigue. And meta-analysis that evaluated over 12,000 patients, cancer survivors in this case, revealed that the severity is related to the severity. And what that means is that those patients at higher risk with more advanced disease or that have undergone more aggressive treatment tend to have more severe symptoms of cancer-related fatigue. So what can we do? One of the first things that we need to focus on is identifying other causes for the cancer-related fatigue in this case. So some patients have an acute drop in the hemoglobin and then that results in anemia that will make them more tired or they're undergoing the course of an infection or they're actively receiving radiation therapy that can get them very tired. So identifying these and correcting these organic causes of fatigue is the first step. But once all these it's more somewhat stable and addressed, then what do we do? And then that's when the patients are like, doctor, do you have a medication for this? How can I get better? And there are some studies that identified rilin or modafinil as some of the medications to help with the cancer-related fatigue. There is not enough strong evidence for this. However, there is very strong evidence for physical activity. And that's in one of those papers that Dr. Sokolov was referring to, physical activity and exercise have been found to be a Category 1 recommendation and is the best supportive evidence for the treatment of cancer-related fatigue. There's a meta-analysis that also studied 44 studies and over 3,000 survivors that identified exercise as the main tool that we have to help our patients with cancer-related fatigue. And when we talk about exercise, there are so many different forms of exercise. So sometimes when we said that to the patients, they kind of like question mark in their head. It's like, okay, what does she mean exactly by exercise? And it's several modalities. In one study on 200 breast cancer survivors found that yoga could also help them to be better for the treatment of cancer-related fatigue. And it kind of makes sense because if we go to the possible theories of how cancer-related fatigue happens in the cancer patients, one of the most common theories is that cancer and its treatment releases some pro-inflammatory cytokines that also cause this sense of tiredness and mental fog that the patients often find themselves in. And then also it's associated to muscle wasting and musculoskeletal deconditioning. And exercise is a great tool to help with these specific issues. Some studies have shown that exercise can help with the decrease the pro-inflammatory cytokines and as well as improve endurance and increase the muscle bulk to fight the muscle deconditioning. So also if they do the exercise during the day, during the sunlight, it can also help them regulate the circadian rhythm, which is also one of the theories for the cancer-related fatigue. So with that being said, what can we do and how do we tell our patients to exercise specifically for cancer-related fatigue? And one of those papers that Dr. Sokolov was mentioning is the round table that talks specifically about how to help the patients with cancer-related fatigue and what is the minimum dose for these patients. So the question is, do we ask them to do moderate to vigorous intensive exercise, or should we ask them because they are tired to do more low-intensity physical activity? And the evidence is robust to suggest that moderate intensity exercise will be more helpful in these patients with cancer-related fatigue. And it's not only the aerobic exercise, but some resistant exercise in a moderate intensity as well can help them. The recommended amount of time is 30 minutes and the recommended direction of an exercise per hour is 12 weeks. However, I often tell the patients it's contraintuitive, right? Because if you have cancer-related fatigue, if you're tired, your mind is telling you, okay, let's rest today. I had a big day. Let me take a nap. And then tomorrow I'm gonna be stronger. And although some energy conservation techniques can be helpful, the main way to convey the cancer-related fatigue is to do actually exercise. So that's the first thing that we need to help the patients understand. And then when we do that, what type of exercise will be helpful for them? So it is very helpful that in these guidelines they give us more specific recommendations that we can put into that nice exercise prescription that we just saw recently. And for this specific cancer-related fatigue, the use of three times a week or 30 minutes moderate intensity in addition to two times per week, two set of 12 to 15 repetitions in the major muscle groups have shown strong evidence and it serves as our primary tool in the treatment of cancer-related fatigue. Once a patient have a better stamina and is able to participate in more activities of daily living, their job, their hobbies, they're gonna have a better overall sense of well-being. However, there are other issues that can affect the overall well-being of the patient. And some of them are referring to mental health as well as the health-related quality of life. And what can we do for this? But it's very difficult to address these issues because yes, we can give some patients some antidepressants and we can send them to psychology and psychiatry to help us manage some of these regulations of neurotransmitters. But there are more issues that are related to the cancer-related overall well-being. Some of them are related to physical problems and psychological stress, adverse event, and even financial distress. So it's very hard to identify one specific issue on how to fix it. You think that we need multiple treatment options and multiple strategies to address the issues of these patients. However, exercise seems to be a one tool that we can use and that can affect different settings and that overall can improve the patient's well-being. But again, we go back to the question mark of what is the best way to do it and the duration, the frequency. If we tell our patients to exercise in general, they are less likely to do it instead if we give them specific recommendations on what to do and how to do it. So this is another meta-analysis that included 34 randomized clinical trials and over 4,000 patients. And they were evaluating the exercise in quality of life and physical functioning. And the good thing about this meta-analysis indeed it shows that exercise can help improve the physical activity and the quality of life and physical function of the patients with cancer. But the part that I'm more excited about is the fact that they didn't see any significant difference between the different groups. Meaning that exercise work regardless of the age, regardless of the gender, the sex, the level of education or the staging of the disease. So if you go back to that first slide that I was showing you with that list of things that affect this condition, then we can identify that a lot of those are crossed by the fact that exercise can help in each one of these conditions regardless of the BMI or the cancer title, the stage of the disease and the treatment that the patient is undergoing. So physical activity following the cancer patient, the cancer treatment can also help with the process. So when we go to the most more specific treatment options, then we have here again, the recommendations of the round table. And we can see that in the areas of anxiety and depression, there was very strong evidence for aerobic activity. However, insufficient evidence for resistant activity, resistant activity only. So this doesn't mean that resistant activity only doesn't work. It's just that the evidence out there is not strong enough to support it. However, the aerobic activity plays significant role in anxiety, depression, as well as health related quality of life regardless of all the other factors that I mentioned earlier. A combination of both is very important and it's found more helpful in this patient population. And one thing I would say is that, when we recommend to the patients to do it for a certain amount of time, a minimum of 12 weeks to see difference, we have to set very good expectations to our patient population and tell them, it's okay, you're gonna feel very, very tired and very fatigued after the first day or two of exercising. I will feel very tired too if I wasn't going to the gym or doing that. And let them know that it's okay to feel that way. And that is not a reason to give up on their exercise regimen. And to give it a good chance of doing it religiously for a certain amount of time so that they can actually feel the effects of the exercise in their wellbeing and quality of life as well as the cancer-related fatigue. So that is very, very important. Set up the expectations and let them know that it's okay to feel tired, but it will get better. And the other thing is that, not to give up the first couple of weeks, give it at least 12 weeks to see how they're influencing. That I always tell them, like, if I go to the gym right now, I'm not gonna get super fit if I go for only like two times to the gym and then I'm like, okay, I'm not fit, let me just give up. We have to keep doing it. And we as a physician and every part, every member of the team are the cheerleaders of these patients to continue to do that. Our role as physiatrists is also to identify those barriers that are not gonna allow these patients to participate in the regimens of rehabilitation or the exercise that they can do. So that's another component. And close follow-ups. Usually we're saying, well, you know, this patient is only exercising. We can see them in three months or four months, but sometimes checking on these patients and encouraging in the middle of their routine can help them to have more adherence if it's not possible to do this exercise under supervision. So the other thing to keep in mind is that some of these patients will have some limitations in terms of precautions that they need to have with exercise and the time of doing exercise. So some of them are those patients with metastatic disease, especially to the bone or that have poor bone health quality. And for that, I'm gonna pass it along to the wonderful Dr. Jennifer Bayman, who's gonna talk about some of these issues. Thank you very much. Disclosures is written, back again today, dropping some sweet exercises your way, not in the frame. I do have a third disclosure. I only wrap during pandemics. These are the objectives. Breast cancer patient fell, broke her arm while being treated, had to assess her bone health or improvement could not be completed. She did well with physical therapy and bone-targeted agent. Fortunately, it was non-displaced, which affects treatment. What's the big deal about, in cancer bone disease, why is that kind of a big deal? Response criteria based on bone repair, talking about it gives me a thrill. So many cancer treatments have an effect on the bone. Gotta let our patients know, not going through this all alone. Latest ESMO guidelines, bone-targeted agents for all, depends on disease location and severity. Get on the medication before you fall. Recommendation separated out by myeloma and mets, mostly zoledronic acid is your best bet. Weight-bearing status better be in the chart. Size of the lesion affects where you start. Greater than 2.5 centimeters or 50% lysis in the area of the lower limbs makes weight-bearing a crisis. Radiographic appearance of pathologic fracture here, still looking pretty bad. A difference might not appear. This patient also had lymphedema, an important concern, joint disarticulation, and a nerve that burnt. Diagnosed with CRPS due to bone scan result, this patient had lymphoma. Arthrosynthesis yielded no doubt. Check out her images after chemo. Even I can see a change. Remineralization on X-ray, the bone did rearrange. Changing the mechanostat is just fun to say. Mechanical engineering and bone mets, exercise making bones stay. Kind of fascinating how cells respond to stress, may decrease cancer. Wouldn't that be the best? Breast cancer mice with pathologic fracture, jumping all around. Glad to see bone coming back with exercise in town. Loaded bone on left, no exercise on right, tumor on the bottom, control showing up white. I will always say exercise is the best medicine. Actually, bone targeted agents with a greater effect on the shape you're in. Surprising me for sure, more aerobic than resistance. Turns out any force applied to the hip and the spine can really go the distance. Prostate exercise cohort, oh, whoops. Prostate exercise cohort shows it's really safe. Aerobic resistance flexibility, use the body glide before you chafe. Improved physical function and strength of the lower limbs in the average age of 70 mets in the pelvis, femur, lumbar ribs. Here you see a breakdown of who exercise professionals ask when they have the question, could a patient with bone mets do this task? Not cool, we're at the bottom of the list of consults. Let's take it as an opportunity, not as an insult. Ask about prior treatment and medications is for real if you wanna consider how to help them heal. In summary, think of exercise, even in the fracture setting for improvement in bone health. In 2021 on team physiatry, I am betting. Now I'd like to turn it over to the fantastic Dr. Malter. We thank her for bringing us all here today. Thank you, Dr. Behma. There is nothing I can do that can follow your rap. Okay, but I'm happy to talk to you guys about some of the barriers that I frequently encounter, which is cytopenias and lymphedema. Done, I'm just having difficulty advancing my slides. Okay, so very frequently the patients we see are undergoing chemotherapy, radiation, and especially patients with hematologic malignancies may have something called myelosuppression. So myelosuppression is suppression of all the cell lines of the bone marrow, which will cause thrombocytopenia, anemia, and neutropenia. And in the past, the dogma was that if you are cytopenic, neutropenic, and anemic past a certain point, you should not exercise. And actually in the 80s, patients who were undergoing induction for AML and ALL and had platelets below 50,000 and hemoglobin below eight could not exercise at all and were actually advised to have bed rest. So why do people have cytopenias? Chemotherapy, steroids, radiation therapy, as well as immunosuppressive therapy for patients preparing to undergo bone marrow transplants, all these can combine to cause cytopenias. And one of the questions that I'm asked most frequently by consultants, oncologists, and our own physical and occupational therapists is at which point in time is it no longer safely possible for a patient to undergo rehabilitation and to exercise? So let's start off with anemia. Although there have been studies showing that aerobic capacity certainly is improved at higher levels of hemoglobin, there have not been any studies that show a cutoff below which exercise is not possible. So if you look at the effect of hemoglobin on exercise, we know that decreased hemoglobin can decrease endurance, exercise tolerance, aerobic activity, and leads to fatigue. And as we know, these can often become like a vicious cycle in that one can contribute to the other. So if we apply just common sense guidelines to patients with anemia and take into account studies that have been done having shown no adverse events for patients who have hemoglobin below that of normal, we can say that patients that have a hemoglobin below 11 can exercise safely as long as they're monitored with vitals and as long as we understand that those patients can become tachycardic and they can become orthostatic and it's really important to educate our patients on symptom monitoring. So we definitely wanna have self-perceived exertion monitoring. And we want to educate our patients about dyspnea, chest pain with exertion, feeling lightheaded or orthostatic, and help control for those factors. For patients that have a hemoglobin less than 8, again, we want to have symptom monitoring. And those patients may need a transfusion if they're symptomatic. However, if they're asymptomatic, patients can have short interventions with exercise and just have to be taught energy conservation practices. Thrombocytopenia. So thrombocytopenia is probably one of my favorite cell lines to talk about and probably what I get asked about the most. In the past, patients were really encouraged not to do any kind of activity or any kind of exercise below 50,000 platelets. And with time, we've kind of learned that it's not as much the absolute number of the platelets, but more the rate of change. So if somebody is on chronic chemotherapy or if somebody is undergoing induction from bone marrow transplant where we can expect them to be cytopenic for a very long time, we can tolerate a lower platelet counts. So for example, in a review of exercise studies on thrombocytopenia by Marashida et al, they actually found that there have not been many adverse side effects of patients exercising even at a platelets below 20. So when we talk about studies evaluating bleeding, which is really what we are most concerned about, we have to just come up with some precautions for our patients to minimize their risk of bleeding, both intramuscular and intracerebral. So if we go by that, we were going to say that patients that have platelets over 30,000 can engage in moderate exercise and light resistive training. Patients that have platelets between over 20,000 but less than 50,000 can engage in light exercise but have to have close monitoring, especially with their blood pressure. So you don't want their blood pressure to go above 170 over 100 in order to prevent any kind of bleeding complications. Patients that have counts between 10,000 and 20,000, this is the group that is probably the most challenging to handle and the one that has the most questions. So this is probably the group that can do very light exercise and can have some resistive exercise, but we wouldn't want these patients to use machines. We want just to use very light weight in order to prevent, again, that intramuscular bleeding complication. Most patients that have platelets below 10,000 should be transfused. Neutropenia, so I think a lot of us have experience taking care of neutropenic patients, especially on our acute rehab units. I do get frequent questions about when is it safe to exercise for patients with neutropenia and where should they do this exercise. So common sense would say that patients who are neutropenic should not go to gyms, should not go to pools, should not go to public places to exercise. However, again, with neutropenia, just like thrombocytopenia, it's not the exact number. It's the rate of change. So if the patient is chronically neutropenic, it should be safe for them to engage in exercise at home or outside. And the thing about neutropenia that I think a lot of people miss is that the greatest risk to a neutropenic patient is not necessarily coming in contact with other people. The greatest risk is from their own secretions, from their own body flora. So in this study, a very small study of 12 patients undergoing induction, they really wanted to assess to see if patients that had critical cytopenia in older cell lines were able to exercise safely and effectively. So these patients underwent strength training, submaximal intensity. And as you can see, their target heart rate was to make sure they were submaximal. And they found in these 12 patients no bleeding complications. And they were able to tolerate their exercises safely and effectively. I want to just switch a little bit from cytopenias to lymphedema. This is something that I hear about almost on a daily basis when I treat lymphedema patients. I hear them talking whether it's safe for them to exercise. As you can see in the slide, lymphedema is very prevalent, especially in patients that have breast, GYN, and sarcoma cancers. The risk factor number one is lymphadenectomy. But certainly, patients that have had any kind of surgery or radiation are at high risk for lymphedema. When patients come to me, they have already done their research on the internet. That research has told them a lot of misinformation, some of which is listed here. But the one that I want to focus on is they were told that they should avoid vigorous exercise and that vigorous exercise can exacerbate their lymphedema or cause lymphedema. The thing that I love to dispel the most for these patients is to encourage them that vigorous exercise is OK with lymphedema. And actually, as you can see in the studies we're about to do, exercise may prevent the exacerbation of lymphedema. And when we talked earlier about bone health, especially for our breast cancer patients who may have had chemotherapy, radiation, and may be on aromatase inhibitors and may have early ovarian failure, nothing is more important for these patients than exercise and especially strength training. So in this study, looking at 154 patients, patients were encouraged to do strength training with the exercises, as you see here. And what was cool is that there was no limit placed on the amount of weights that they could lift. So if somebody was a beginner, they started at 5 pounds. But if they were further along in their fitness, they could do whatever weights they wanted to. And what they found is that they compared the patients going through strength training versus just aerobic exercise. And what they found is that in patients that underwent strength training, less of them had exacerbations of their lymphedema than their control group. What's more interesting is that they found that patients that were at higher risk for lymphedema and lymphedema exacerbations, which is those patients that had more than five lymph nodes removed, those patients did even better. To me, looking at this study, I would prescribe lymphedema and strength training exercises as a way to prevent lymphedema and lymphedema exacerbations. Here's another study looking at the same. So basically, 140 patients were enrolled in a trial to see whether weight training could exacerbate lymphedema. And as you can see, patients that were in the intervention group had less swelling, had less severity of symptoms, less exacerbations, but improved upper extremity strength, which is obvious. Again, this is another great study that shows that exercise is medicine. And for a condition like lymphedema, for which we do not have a lot of treatments, this is a prescription for something that patients can do to improve their outcomes with lymphedema. That's all I have. Thank you for listening to me. And now we'd love to have some questions. So I will read some of the questions that we got in the chat. And I'm hoping my colleagues will be able to answer them. So question number one, are oncologists talking about fatigue? Or is PM&R being consulted only when patients complain? Meaning, are oncologists in your institution screening for fatigue? Sorry, Dr. Molinares, do you guys want to take that one? Yeah, I think Diana, do you want to take that one? Dr. Molinares? Go ahead. Since you spoke about fatigue, you want to jump in on that one? Or I can take it. OK. Can you repeat the question? Yeah. So basically, are oncologists at your institution screening for fatigue? Or is it only when patients complain about? What is the screening for fatigue at your institution? Can you guys hear me? Now we can. Yeah, at my institution, it's really important. Oh, sorry. It looks like there were some technical difficulties. So yes, I'm happy to answer that question. So here at Sylvester Cancer Center in Miami, right now, it's very provider-dependent. So there are some oncologists, especially those in GYO that work very closely with us, are asking specific about fatigue and about function, like how much they walk and how much they participate in activities. So they are referring patients specifically for cancer-related fatigue to us. And there is a project with the survivorship group that is putting some patient-reported outcomes into a regular screening in general oncological clinics. And some of the questions are also asking about fatigue and creating automatic referrals depending on the level of fatigue and the level of function, either to PM&R or to physical therapy or both in some cases. And then some other patients that we are getting because they are requesting to see a rehabilitation physician. But I would say most physicians and the cancer center is making a big effort in identifying and screening these patients. And at the same time, some oncologists are working more into identifying patients with low functional status and cancer-related fatigue. So it's getting more and more common. OK, thank you. Next question. Dr. Sokoloff, this question, I believe, is for you. Should we push patients who are over the age of 65 to get 150 minutes of moderate intensity exercise as recommended by the ACSM guidelines? 150 minutes is what I try to get my patients to strive for. But it's the 90 minutes is what's been shown to actually be beneficial to help improve cancer-related health outcomes. So that would be fatigue, physical function, lymphedema, just overall improved quality of life. That is actually, they don't need to get the 150. They can actually get away with doing the 90. I always encourage combining that with two days a week of strength training. So we set the bar low. It's always start low and go slow. I tell them what the minimum dose is, but I encourage them to get to that 150-minute mark. But we have good data showing that less is actually even effective. Next question, do you recommend using a compression sleeve with exercise for lymphedema patients? So as far as I'm aware, there are no studies showing that a compression sleeve prevents lymphedema exacerbation in patients. What I do with my patients is I tell them that everybody is an individual and that even though I personally have not seen the studies showing that a compression sleeve will cause an exacerbation during exercise, and in fact, I think the more the arm can move freely and have blood flow, the better it is, I do tell patients that I have heard reports that patients may feel heavier after exercise. And I say, if you're one of those people that feels heavier after exercise, by all means, go ahead and wear a compression sleeve. Do you guys agree with that? Or do you have different protocols at your institutions? I agree with that. You're right. We don't have great evidence supporting the use of a garment if a patient does not yet have lymphedema. It would be interesting to know if there's preclinical lymphedema, so through the use of various measures, bioimpedance and so forth, perhaps that might have any bearing, but as far as I know. So it's not something that we typically recommend unless they actually have lymphedema. In other words, we don't use compression garments as a preventative measure. OK, next question. Given the low adherence of physical activity among the general population, and especially cancer patients, should the default assumption be to initiate these discussions early on in the cancer treatment by the oncology team? Yes, yes, and yes. Dr. Baynes, do you want to talk a little bit about rehab and exercise in this realm? So prehab is pretty much anything you do before chemotherapy, radiation, or surgery to improve outcomes after. So my struggle, I would agree, my struggle is that patients are not exercising, not that they are. And I'm here in Worcester, Massachusetts, which is a socioeconomically depressed area. It's really hard for patients to pay their co-pays, to have a nice place to work out, regardless, even before the pandemic. So I think no matter what you do to get people moving, that is a good thing. And I love this initiative that Dr. Sokoloff talked about in his talk, because it's just, I think it's changing, it's changing disparities in health care as well as improving cancer care. I would add something to that comment in terms of having the oncologists help us motivate the patient. And I think that it's absolutely the case. One of the things is to educate our oncology colleagues about the advantages or the effects of exercise so they also feel confident and comfortable recommending exercise to the patients. We have here at Miami a multidisciplinary clinic for cardiothoracic oncology surgery. And the pandemic has helped, in a sense, because now we have a multi-day through Zoom. And in that multi-day, the oncologists say, well, if you don't do the exercises that Dr. Molinares is recommending, it's going to be very hard for me to operate on you. So that usually gets them going. So I think educating the oncology colleagues and the surgical oncologists is part of the strategies to get the patients motivated. OK. Next question. Does the exercise have to be 30 minutes at a time? Is 10 minutes three times a day OK, three times a week? It does not have to be 30 minutes at a time. Matter of fact, it's a lot easier, I think, for patients to break it up. I think there's good evidence, though, that 10 minutes of sustained aerobic activity is probably better. So they could do 10, 10, and 10, 15, and 15, but at least 10 minutes of sustained aerobic, moderate intensity aerobic exercise is what I typically recommend. OK. I think our time is almost up. I know that we have some questions that haven't been answered. Please feel free to contact us, and we'll be happy to answer any questions that you have. We'd love to answer those questions. It was great to have you all chat about breaking barriers in cancer rehab. And I'm hoping this talk was informative, as informative for all of you as it has been for me. And I hope to see you guys again soon.

Exercise Medicine

Breaking Barriers

Cancer Survivors

Importance of Exercise

Exercise Prescriptions

Moderate Intensity Aerobic Exercise

Strength Training

Cancer-related Fatigue

Moving Through Cancer Initiative