Episode 11: Exercise and Cancer

[0:00:00 Speaker 1] We are a resource for learners, including every member of the Livestrong Cancer institutes on track educational pipeline from middle school to residency. We are growing collection of interviews, talks and experiences that uncover the myths and the uncertainties of cancer and careers in cancer in order to empower and inspire generations of thinkers and leaders. This is cancer uncovered, an education and empowerment podcast by the live strong cancer institutes.

[0:00:43 Speaker 0] Hello,

[0:00:47 Speaker 2] this is Kristen win senior

[0:00:49 Speaker 1] programme coordinator

[0:00:50 Speaker 2] here at the Livestrong Cancer Institutes, an emerging cancer center at Dell Medical School at the University of texas at Austin Hook em horns. Before we jump into this episode, I want to introduce you to this month’s host, Britney Fernandez Brittany, while

[0:01:07 Speaker 1] wrapping up her last

[0:01:08 Speaker 2] semester of her undergraduate degree at the University of texas, came on board in january of 2021 as a part time student associate for the L. C. S. Administrative team, helping to coordinate and execute our multidisciplinary tumor board meetings which are the

[0:01:24 Speaker 1] cornerstone of our

[0:01:25 Speaker 0] clinical work at the cancer

[0:01:26 Speaker 2] center where

[0:01:27 Speaker 1] clinicians across

[0:01:28 Speaker 2] disciplines come

[0:01:29 Speaker 1] together to discuss

[0:01:31 Speaker 2] and create the best possible care plans for patients. We also

[0:01:35 Speaker 1] discovered that Britney has a heart

[0:01:37 Speaker 2] for education and was an intuitive, compassionate

[0:01:40 Speaker 0] contributor to the work

[0:01:41 Speaker 2] that L. C. I. Does with high school and middle school students. When we told Brittany about our education and empowerment podcast, she jumped at the chance

[0:01:50 Speaker 1] to help out

[0:01:51 Speaker 2] the episode you are about to

[0:01:53 Speaker 1] hear is her

[0:01:54 Speaker 2] creation and we couldn’t be more excited to share it with you. As

[0:01:58 Speaker 1] this episode

[0:01:59 Speaker 2] launches, Britney is currently taking part in LCS summer undergraduate research fellowship or surf.

[0:02:06 Speaker 1] And we’ll spend the next 11

[0:02:07 Speaker 2] weeks conducting community based cancer research with dr Lillian Noelle, who

[0:02:11 Speaker 1] you heard in

[0:02:12 Speaker 2] episode seven, part one and three. Thank you Brittany for your hard work and dedication to the mission of the livestrong cancer institutes. We cannot wait to see what the future

[0:02:23 Speaker 0] holds for you

[0:02:24 Speaker 2] as you continue your academic and professional career in health care and

[0:02:29 Speaker 1] now I’ll

[0:02:30 Speaker 2] let Britney take it from here.

[0:02:35 Speaker 1] This is Brittany Fernandez with the Livestrong cancer institutes and I’m excited to be your host for this month’s cancer uncovered podcast. As a graduate from the University of texas at Austin’s Bachelor’s of Science and kinesiology program. I was excited to hear about the amazing work being done at L. C. I. And exercise and rehabilitation as an intervention for surgery. We had the opportunity to speak to Dr Declan Fleming a surgical oncologist at the Livestrong cancer institutes and physical therapist. Dr Britney chesser about their work with cancer patients and pre happy for surgery and postoperative physical therapy. This is cancer uncovered. Exercise is medicine has been a global initiative piloted by the american College of Sports Medicine for years. But what made you decide to integrate exercise and preoperative oncology care

[0:03:27 Speaker 0] in recent years? There’s been a lot of study actually trying to figure out ways to quantify whose at higher risk and who’s at lower risk. There have been these batteries of different tests that have been developed that tell us if a person has something that places him or her at higher risk for problems related to surgery. All right. So the concept of exercise as a part of helping a person to recover from surgery really stemmed from us recognizing that some people are frail and then not just throwing up our hands and saying, oh well too bad. But saying, you know what maybe we can make people less frail by doing some really specific targeted things. And what we’ve chosen to do is we’ve chosen to say that and out of shape person with some work can be put into better shape. A poorly nourished person with some purpose. Behind the way we give them nutrition can be put into a better nutritional status and most surgeries are not emergencies. You don’t have to do them that same day, the work that’s been done recently, all throughout the world really. There are great groups that have been looking at this in spain and in the Netherlands and in the UK and in Canada. And several groups in the United States have been looking at saying, is there a way instead of putting a person through a surgery and then having to let them rehabilitate after the surgery and maybe sending him to physical therapists or to a nursing home to recover. Is there a way we can preh ability ate them to give them that strengthening exercise and that nutritional instruction beforehand to get them into a place where they are better able to recover from the from an operation. In fact, orthopedic surgeons have been doing preh ab right I’m just looking at it instead of as let’s get a joint ready I’m looking at it, let’s get a whole person ready. And then I began to say well I’ve got weak patients. What if we make them wait a week or two longer for surgery and we get them to work with a trainer. And so I am really fortunate to have a very long term friendship with two members of the faculty of the Department of Kinesiology and Health Education at the University of texas. The names of Phil and dixie SAn fourth and I reached out to the stanford and said hey is there a way we could try to get some trainers to work with our patients to see if doing preh ability ation will help them out. And I had no idea what creative thinkers that fill in dixie were because as soon as I did that, they got us plugged in with the chairman of the department who said that’s a great idea that supported and with this great exercise physiologist named uh Hero Tanaka and Hero has been for years working with athletes to prepare them for major competitions and of course his mindset was well, we train people up for an event and surgery is an event, let’s train them like we would train an athlete and we’re going to have to modify things, but the concept is the same and that’s how our preh ab project at the University of texas was born,

[0:06:59 Speaker 1] wow, that’s brilliant. I love the analogy of surgery as an event that you’re training for now. You’ve referred to this exercise program as preh Ab a few times. Could you define that for our audience? Preh Ab

[0:07:15 Speaker 0] is going through purposeful work to get a person ready for in my case for surgery. But you could preh ab for a person going through chemotherapy or something else like that. I think this is broadly applicable to complex medical problems, but I’m going to speak to it about surgery. Alright. Surgery taxes people physically nutritionally, it taxes their immune system and then it also attacks is them emotionally and intellectually right? And Soap rehab is purposeful work to get a person physically stronger nutritionally in the best state possible to boost their immune system and then to prepare them mentally and emotionally for going through a surgery and the process of recovery from that.

[0:08:07 Speaker 1] You know, I think you bring up a really good point. Sometimes we really only think about the physical aspects of surgery and not the mental and emotional aspects but now that you’ve defined the whole person approach to pre habit. Could you tell me more about the trials you conducted and the programs outcomes?

[0:08:25 Speaker 0] We did a trial and we just called it a pilot project because we didn’t have a lot of like national grant funding support for this. But we wanted to see number one if people would agree to delaying their surgery to go through a period of exercise nutritional support before they did the surgery because that was actually a big question. Everyone basically I take care of in my practice has a cancer. And when you ask a person when they want to have their surgery for cancer, they say today right, nobody wants a cancer sitting around in their body and I don’t want to leave it sitting there. But if I can do something that’s going to speed their recovery and make it better, it’s worth a little bit of weight before the surgery to get a person ready. All right. So we started this trial program and what we found out was that yes, indeed, people were willing to do something to get themselves ready for surgery. What was really surprising was as we started the program to get into it, the people had to have an initial assessment where we have them do some physical tasks and some mental exercises and things like that. And the number of people that were a lot more week or more frail or had bigger problems than they recognize was astounding. I mean, probably two thirds or more of the patients when we have them do their intake exercises performed significantly lower than they thought they were going to and that I think as much as anything else convinced them that yeah, you know, getting myself stronger before I go through this is really something that’s useful and probably 95% or more of the people that went through AARP rehab program. And it was a four week program. So it wasn’t like people had to wait six months to get their surgery. They did four weeks during those four weeks, two times they came to the University of texas to Belmont Hall where the department of kinesiology and health education is to work with a trainer specifically. And they got taught what they were going to do. And then they had a video to watch at home and they followed this exercise pattern and they actually wore blood flow restriction device which is basically like a blood pressure cuff. And you put it on the top of the arms and the top of the legs. And it allows the body to experience the same sort of physical benefits from doing a high intensity exercise program but at much lower intensity because you diminish the blood flow. So the muscles experienced the depriving of oxygen and nutrients during the exercise the same way they would if they were going out running wind sprints up giant steps or something like that. So their level of benefit was dramatically increased using this process that dr tanaka suggestion we used without doing something that would take a cancer patient and wipe them out. And because of that they were able to do something every day. They did resistance exercise using some bands or some light weights one day and they did walking exercise the next day and they alternated that and did it every day and every day. They got some nutritional supplementation associated with their exercise to help build protein and improve their immune system. And so they did that for four weeks. And for almost the entire four weeks they were at home we would check in with them by telephone or by text, but it wasn’t like they were having to go to the gym and pay money for it or anything else like that. And 95% of the people that we took care of said I noticed a significant improvement in the way I felt from the time that I started until right before the surgery and I feel more confident about the surgery and we know what we did work because we were able to measure their body composition and during those four weeks on average, people lost almost £2 of fat weight and gained about a pound and a half of muscle weight. They improve their exercise stamina intolerance, so their strength and their stamina got better their ability to do repetitive tasks and to be able to walk further improved. And then in our pilot we actually looked at how long they ended up staying in the hospital compared to a group of people that had problems similar to theirs and we’re going through operations similar to theirs. And we found that the amount of time that they stayed in the hospital was about five days, lest it went from about 10 days down to about five days to the length of stay in the hospital. And on top of that, the incidence of having a complication, like an infection or a blood clot or problems with breathing went down dramatically in the group that did preh ab so I know that at least in this small first trial it wasn’t like we were looking at hundreds and hundreds of patients, we had 21 patients that we did the exercise for. And we compared them to 71 patients that didn’t do the exercise program. So it’s just the beginnings of a project but our results were so dramatic that we feel really encouraged by that. And similarly if you look at the work that a group in spain, some people up in michigan, some people in the U. K. And some people in Canada have done. They’ve shown also that patients who go through a pre habit program have lower likelihood of bad outcomes and shorter length of stay in the hospital as compared to the people who don’t do it.

[0:14:02 Speaker 1] You know my passion for kinesiology really stems from my awe at the capabilities of the human body and I think that these capabilities are really exemplified by the success that you saw in such a short four week program. I know you mentioned some other groups are also doing this type of work, but what aspect of this trial would you say make your team’s approach so successful?

[0:14:26 Speaker 0] What I think is really unique in the thing that we did here at the University of texas is that we figured out a way to sort of cheat the system and using those blood flow restriction bands, I think is giving people that couldn’t otherwise do hard exercise the way that they were trying to get them to do it up in Canada and in the UK and in spain. And that is the thing that I think is unique about what we tried here and what is so encouraging about the approach that we have is I think it opens up opportunities for people who might not have been able to do this sort of training to get into it as well.

[0:15:04 Speaker 1] What I think is so special about the work you’re doing is that it truly gets to the root of what is whole patient care. And I think part of that picture is really bridging the disciplines between fields like exercise physiology and surgical oncology. As you’re doing now,

[0:15:21 Speaker 0] you’re exactly right. I think, for far too long in traditional Western al empathic medicine, we were so focused on the technique of let’s do a surgery, right? Or let’s find the right medicine to give that the pendulum is now swung into an area where we’re recognizing the benefits of looking at the whole person and addressing their whole life, right? Because my goal isn’t to take out a surgery to cure cancer, although that’s part of the goal. My goal is to try to restore someone’s health and allow them to live as long as possible with this high quality of life as possible. And if you’re doing that and you disregard what’s going on with them personally or financially or emotionally, then you’re cheating them from having that benefit of addressing what’s important to them in life. And so instead of just being doctors that focus on the medical or the surgical aspects of treatment, we have to become holistic providers.

[0:16:25 Speaker 1] I couldn’t agree more and I think that holistic care really exemplifies a patient centered approach. I’d love it. If you could tell us more about how patient care is practiced at the livestrong cancer institutes

[0:16:37 Speaker 0] here, the Dell Medical School in the Live Strong cancer institutes. We have this calm model which is cancer life reimagined. We are thinking about what life should be like for people that have cancer. And we want to provide the social and the emotional and the financial and the intellectual and the exercise support to give them the best chance of really having a great outcome and having a great life despite dealing with their cancer

[0:17:08 Speaker 1] that’s phenomenal. And it’s very clear that you’re passionate about the work you do and the mission of L. C. I. I’d love it if you could tell us how you got here and what made you decide that surgical oncology was really the best fit for you

[0:17:24 Speaker 0] in medical school. As I began to look at the different specialties, I really found that the one that resonated most deeply with me intellectually and emotionally. I felt like it was a challenge was surgery. And at first I thought I wanted to be a trauma surgeon because I thought would be really heroic to save people. But what really engaged me most as a person was not the drama of doing trauma care, although that that is awesome. It was the complexity of doing difficult cancer surgeries and the emotional tie that I got to make with the people that I’m taking care of. Because with many surgeons, you’ll see a person one time before you do an operation, you do an operation for him, they’re off to their life and you never see him again. But with a cancer patient, we’re gonna be doing things for them leading up to the time of the surgery and I’m going to get to know what’s going on and I’m going to be checking in with them. I’m going to find out how they’re doing, going through chemotherapy. And then even after I’ve done the surgery, even if we believe that we’ve cured a person, we’re still having them back in. And I see people at three or six month intervals for checkups. And so I think that I came to figuring out that I should be a cancer surgeon. And I think that’s one of the really beautiful things about health care is that you are always working with other people towards a shared goal. You are always getting to team with somebody that’s the patient. And there is room in this profession for people who love doing different things right now, being a doctor isn’t the end all be all literally, I think that anyone could find something in health care that would speak to them as a person and give them something to do that’s meaningful.

[0:19:07 Speaker 1] Dr Declan Fleming did a phenomenal job, breaking down the research he’s conducted on pre hub for surgical oncology and providing us insight into his work and the work of the live strong cancer institutes at delivering on their mission of cancer life reimagined Next Britney Chester will share about her part in delivering whole person patient care for cancer survivors in her role as a physical therapist. For a long time. I had no idea that there are actually subspecialties that physical therapists can pursue. And I’d love to know more about why you chose to specialize in oncology rehabilitation as opposed to another specialty. My grandmother had breast cancer way before I was born, but all throughout my life I saw her struggle with the lasting side effects she had from breast cancer, such as pain in that arm swelling. She had a real difficult time using that arm. And I really wanted to know how I could help her and others who are battling with cancer in its long term effects. So once I became a physical therapist, the revital certification program really helped me to build my knowledge and specialized in the oncology patient population for rehab. I think it’s really amazing that you saw a need for this type of rehabilitation and decided to pursue it as a career. Honestly, this is the first time I’ve heard of physical therapy for cancer survivors and I’d love it if you could tell us more about the benefits of physical therapy and how it can improve a cancer patient’s quality of life. So physical therapists work closely with the physicians to provide the patient with a guided program that’s tailored to them to gain mobility, to build their strength and regain motion. Physical therapy is a part of a team of providers that helps oncology patients to safely return to their previous level of function and the things that they love to do with this specific cohort. We have been working alongside dr Fleming most of these patients either haven’t moved in a long time, they’re afraid to move or they have multiple comorbidities that limit their activity tolerance. We also provide the patients and their families with education on posture, easier ways to get in and out of bed walking and then home exercises that they can do when they don’t come into the clinic help improve their aerobic endurance and their strength. I’d love it if you could elaborate on the relationships you build with your patients and how you tailor a whole person approach for patients coming in for pre have and post operative physical therapy In the beginning it’s all about learning as much as you can about the patient from their past medical history to what motivates them, you have to gain the patient’s trust. So most people only think of therapy as pain and torture or that it’s going to hurt and it’s something that they don’t want to do. So the pre have program is tailored to each patient specific needs and their mobility requirements. And during that 3 to 4 week rehab program, the patients see improvements in strength and mobility. They may even lose some weight in the process and they feel better mentally and physically after doing them. That’s fantastic. And I think the truly amazing thing about exercise is that it is the tailored approach and working as a fitness instructor. Even at the fit institute of texas. Oftentimes I’d have students who didn’t think they could participate because of the rigor of a class. But the really wonderful thing is that there’s a modification that can be customized to each individual. And that really holds true in the work that you do with the cancer patient population now and the patients that you’ve worked with. Could you tell us more about how they responded to a pre hab program and what’s next for cancer survivors? Post preh ab updates are sent to the surgeon on what we see because we see them three hours a week. And so we send those updates regularly. So once the patient is cleared after surgery, then they will return and come back to outpatient therapy in order to maintain that strength that they gained in the pre hab program, increase their motion after surgery and then they’re able to return to their normal activities and the things they enjoyed prior to certain. I think often times we think of physical therapy as a therapy that’s exclusively for orthopedic rehabilitation and not as often a necessary intervention to surgery and other specialties like oncology. When cancer survivors are recovering from surgery, what are some of the deficits that you work through together with a lot of his patients? They have large abdominal scars and so that’s going to affect everything they do in life from even how they breathe. Sometimes there’s conversations how they roll over in bed. I mean everything we do, our abdominals have to kick in and so if they are restricted in their painful, then they can’t move. And so if we can help with that in any way, then we help every aspect of their life. That’s very true. And sometimes it’s just so easy to underestimate the role that just a few muscles play in our daily lives. But it’s really wonderful that you’re able to offer your help in those situations. And as a patient care provider, I’d love it. If you could share your advice for listeners in our audience who are thinking about pursuing a career in patient care, I would tell students to volunteer as much as you can, see, all the different jobs that are out there in healthcare, join clubs and mentorships, Look into hospital summer programs. And then once you start working with patients, get to know your patients learn what motivates them, learn about their families, their hobbies find the reason that they want to get better and back to their lives because a lot of times the mental is just as important as the physical and you never know how much a small interaction can affect someone else. That’s so true. I always think of Maya Angelou’s quote that people will forget what you said and what you did, but they’ll never forget about how you made them feel. And I think oftentimes the emotional impact of patient care is just as powerful as the physical impact that it makes on others. So that being said, what is your favorite aspect of working in physical therapy? I would say that every patient that walks through the door is different even if they had the exact same surgery, it’s not a cookie cutter approach. I’m not going to treat that patient even though it was the same surgery, the same weight because they’re going to have different deficits, different limitations and they have different goals. So it’s really trying to find that way to get them back to what they love and they’re all different. And so each day I never know what’s gonna walk through the door or what new challenges that I’m going to have to overcome or they’re going to have to overcome and how we can overcome them together. That’s wonderful. Thank you so much for being with us today. Are there any final thoughts you’d like to leave with our audience? The population of people surviving cancer keeps growing every day, which is amazing. But with that comes, you know, the deficits and the different treatments along with it. So it’s just nice to know that there’s ways that we can start to help along this cancer journey with these patients. Mm Thank you to Declan Fleming and Britney Chesser for joining us this month to share the amazing impact they’re making with pre hap and postoperative physical therapy and oncology.

[0:26:48 Speaker 2] Patient care.

[0:26:49 Speaker 1] I’m Britney Fernandez with the Livestrong cancer institutes. And this has been cancer uncovered. For more information about the Livestrong cancer institutes. Check out our website at Delmon dot utexas

[0:27:01 Speaker 2] dot e d u.

[0:27:02 Speaker 1] If you’d like to learn more about the Livestrong

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[0:27:05 Speaker 1] have ideas of topics that we can uncover. Send us an email at Livestrong Cancer institutes at Dell med dot utexas dot e d u. Please make sure that institutes is plural. And if you enjoyed the podcast, please make sure you subscribe. Okay