Value of Exercise-based Oncology Rehabilitation for Cancer Survivors - PowerPoint PPT Presentation

The heart and science of medicine. UVMHealth.org/MedCenter Value of Exercise-based Oncology Rehabilitation for Cancer Survivors Northern New England Clinical Oncology Society Kim Dittus, MD PhD 10/20/19

UVMHealth.org/MedCenter No Financial Disclosures

Physical Activity & Survival: Breast Cancer • Nurses Health Study - Evaluated the impact of physical activity on rates breast cancer recurrence and death • Approximately 3000 nurses diagnosed with Stage I-III breast cancer between 1984 and 1998 • Collected information about physical activity at least 2 years after breast cancer diagnosis Holmes et al. JAMA, 2005

Physical Activity and Survival: Breast Cancer 1 0.9 0.8 0.7 <1hr/wk 0.6 1-3 hrs 0.5 3-5 hrs 0.4 0.3 >5hrs 0.2 0.1 0 Recurrence * Breast Ca Death Total Death # Holmes, JAMA 2005

What if you increase Physical Activity after diagnosis? 1 0.9 0.8 0.7 0.6 No Change 0.5 0.4 Increased 0.3 0.2 0.1 0 Death Breast Ca Death Irwin et al 2008

Physical Activity decreases all cause and cancer specific mortality • Breast Cancer • Colo-rectal Cancer • Prostate Cancer 40-50% Relative Risk Reduction McTeirnan A et al, 2019

Physical Activity Among Cancer Survivors: NHANES 2003- ’06 • 87.3% without cancer DID NOT meet recommendations of 150 min/week • 95.5% cancer survivors DID NOT meet recommendations • Differences by cancer type: – 17.9% ovarian meeting – 3.8% prostate meeting – 3.7% breast meeting Smith et al AM J Transl Res 2011

Steps to Wellness Oncology and Hematology Rehabilitation

Continuum of Cancer Intervention and Oncology Rehab Needs Oncologic Long Term Diagnosis Post Therapy Therapy Survivors Maintain or improve function Restore or improve function Control side effects of cancer/cancer tx Control side effects of cancer/cancer tx Improve strength and fitness Prevent Fitness & Strength Loss Phase 1 Phase 2 & 3 Started Here Aug 2011

Process for Participants Physician/Provider Visit Physical Therapy Evaluation Side Effects Exercise Tolerance Test of Therapy One-on-one Therapy Other referrals

Exercise Tolerance Testing Subset Receiving an ETT - Over age 60 - Received Chemotherapy - Dx of Head/neck or Lung cancer

Cancer Survivors Receive • PT and MD/Provider evaluation • Exercise Tolerance Test • A “tailored” aerobic and resistance exercise program • Opportunity to exercise at cardiac rehab site 2 days per week for 12 weeks • Education classes on site • Weight loss intervention 3 times a year

Data Collected • Physical parameters – Example: Fitness & Strength • Functional Measures – Example: Balance & Range of Motion • Late/lingering symptoms – Example: Fatigue & Sleep • Quality of Life

Characteristics of Participants Gender Female 78.2% Male 21.8% 60.0 ± 11.7 years (Range: 20-84 yrs) Age Type of Malignancy Breast 56.1% Prostate 4.9% Lung 4.5% Metastatic 11.7% 2.4 ± 4.4 years Time since diagnosis (Range: 0.2-27 yrs) Time intervals During initial therapy 21.1% Within a year 47.1% 1-3 years 14.5% > 3 years 17.4% Oncologic Intervention Surgery 80.7% Chemotherapy 62.5% Radiation 63.8%

Sub maximal Aerobic Capacity: 6 Min Walk Test: Female Survivors N=433 Pre Meters Post * 0 100 200 300 400 500 600 700 - 44% Below predicted at baseline - 22% Increase in distance

Exercise Tolerance Test – Peak VO2 (N=372 Females) % 100 71% 80 60 Baseline Post 40 20 0 Very Poor Poor Fair Good Pre Peak V02 = 22.2 ml/kg/min Post Peak V02 = 24.3 ml/kg/min 10.5% improvement ACSM

One Repetition Max Strength Testing (N=393 Females) lbs 200 180 * 160 140 120 Pre 100 * Post 80 60 40 20 0 Lower Extremity 1RM Upper Extremity 1RM 28.2% Increase 43.4% Increase * P of < 0.001

Why is Strength Important? Leg strength and mortality Quadriceps Strength (N-m) measured by isokinetic dynamometer Men Adjusted HR = 1.45 Women Adjusted HR = 1.47 Newman A et al, 2006

Depression, Anxiety & Fatigue 25 20 32% Decrease 15 Pre * Post 10 * 5 * 0 Depression Anxiety Fatigue * p of < 0.001

Functional Impairment In Cancer Survivors % 35 30 25 20 15 10 5 0 Cant walk 1/2 Problems with Unable to mile stairs prepare meals N = 2,218 Cancer Survivors No cancer < 2yrs 2-5 yrs > 5yrs Sweeney et al JNCI 2006

Outcomes of Older Survivors in Onc Rehab (n=361) Percent of Elderly in Very Poor Categories Onc Rehab Population Age >65 yrs Peak VO2 – Very Poor 71.0% 76.1 % 1RM Chest Press 57.9% 67.9% 1RM Leg Press 77.2% 83.9% Functional Measure: 5 Time Sit to Stand ≥ 15 seconds suggests impaired function 24.5% with ≥ 15 sec 5TSTS Baseline Test 5.2% with ≥ 15 sec 5TSTS Post Test

Challenges • Cost • Space • Administration Support • Time • Brick walls 22

What opportunities were in place? • Provider champion(s) • A well equipped location (Cardiac rehabilitation) at reasonable hours • A rehab therapies administrator willing to risk loss of revenue on physical therapy evaluations • Start up funds to pay for an exercise trainer and a little bit of equipment • Ability to generate some clinical revenue • System of referral 23

Financial Structure Clinical Revenue: MD/PA evaluations $40,175 PT Evaluations 26,269 66,443 Donations: + 40,000 $106,443 Expenses: Exercise Trainers $67,586 Scheduler 10,706 Education 7,450 PT Program Admin 15,745 Physician Admin Time 11,102 Non-salary Expenses 2,625 $115,484 24

Institution Benefits • Improved care of cancer survivors • Enhanced public image for the medical center • Training opportunities • Research opportunities 25

Translational Research T1 T3 Oncology Rehabilitation T2 • Retrospective studies using the onc rehab database • Muscle Biopsy Studies • Natural history of the impact of chemotherapy on cardiovascular/pulmonary and muscle function • Behaviorally-based weight loss intervention • Use of technology for maintaining exercise

Critical Pieces • Physician champion • Location • Supportive (risk taking?) administration • System to capture revenue • Some philanthropic support 27

Appreciation to: Research Collaborators • Michael Toth • Philip Ades • Susan Gilchrist • Nancy Gell Oncology Rehabilitation Staff • Patricia O’Brien & Penny Gibson • Nate Kokinda • Diane Stevens & Jamie LeDuc • Rebecca Reynolds & Lucien Benway • Kristie Grover Cardiac Rehabilitation Staff • Patrick Savage • Jason Rengo 28

References • Holmes MD, Chen WY, Faskanich D, Kroenke C and Colditz GA. Physical Activity and Survival after Breast Cancer Diagnosis. JAMA 2005;293: 2479-2486. • Irwin ML, Smith AW, McTiernan A, Ballard-Barbash R, Cronin K, Gilliland FD, Baumgartner RN, Baumgartner KB, Bernstein L. Influence of pre- and postdiagnosis physical activity on mortality in breast cancer survivors: the health, eating, activity, and lifestyle study. J Clin Oncol. 2008 Aug 20;26(24):3958-64 • McTiernan A, Friedenreich CM, Katzmarzyk PT, Powell KE, Macko R, Buchner D, Pescatello LS, Bloodgood B, Tennant B, Vaux-Bjerke A, George SM, Troiano RP, Piercy KL; 2018 PHYSICAL ACTIVITY GUIDELINES ADVISORY COMMITTEE. Physical Activity in Cancer Prevention and Survival: A Systematic Review. Med Sci Sports Exerc. 2019 Jun;51(6):1252-1261 • Smith WA, Nolan VG, Robison LL, Hudson MM, Ness KK. Physical activity among cancer survivors and those with no history of cancer- a report from the National Health and Nutrition Examination Survey 2003-2006. Am J Transl Res. 2011 Aug 15;3(4):342-50 • Dittus KL, Lakoski SG, Savage PD, Kokinda N, Toth M, Stevens D, Woods K, OʼBrien P, Ades PA Exercise-Based Oncology Rehabilitation: LEVERAGING THE CARDIAC REHABILITATION MODEL. J Cardiopulm Rehabil Prev. 2015 Mar-Apr;35(2):130-9. • Newman AB, Kupelian V, Visser M, Simonsick EM, Goodpaster BH, Kritchevsky SB, Tylavsky FA, Rubin SM, Harris TB. Strength, but not muscle mass, is associated with mortality in the health, aging and body composition study cohort. J Gerontol A Biol Sci Med Sci. 2006 Jan;61(1):72-77 • Saeidifard F, Medina-Inojosa JR, West CP, Olson TP, Somers VK, Bonikowske AR, Prokop LJ, Vinciguerra M, Lopez-Jimenez F. The association of resistance training with mortality: A systematic review and meta-analysis. Eur J Prev Cardiol. 2019 Oct;26(15):1647-1665. • Sweeney C, Schmitz KH, Lazovich D, Virnig BA, Wallace RB, Folsom AR. Functional limitations in elderly female cancer survivors. J Natl Cancer Inst. 2006 Apr 19;98(8):521-9 29