(Guest Lecture): February 2024 - Moving Through Cancer

today. We're talking about moving through cancer, which I'm sure that you know because you registered for this event. And the reason why we wanted to discuss moving through cancer, Todd and Diane are going to briefly explain why they chose Dr. Schmitz to talk to us about this important topic. But I know that myeloma is such a journey and there's only so much that we have control over and there is power in taking back what we can control. So that's why this nutrition and wellness for myeloma chapter exists and why we join together to talk about things that we can do in order to improve our quality of life. And one of those things that we have charge over is our physical fitness. Now this doesn't mean that you have to go run a marathon or you have to become a professional bodybuilder, but it does mean that you get to learn tonight what are the benefits of movement and how can those benefits help you to improve your quality of life with myeloma or as a caregiver because both roles are incredibly important. So with that being said, I'm going to turn the time over to Todd and Diane who will then introduce Dr. Schmitz. Thank you. Awesome. Thanks Audrey. Hi everyone. We are Diane and Todd Kennedy, a patient and care partner team and co-leaders of Health Tree Pacific Region Community. We want to thank you and welcome you all for joining us here tonight for this special program. We also want to thank Dr. Lena Romero, a member of our Health Tree Pacific Community for recommending Dr. Schmitz and facilitating the connection that has made this evening possible. So thank you Lena. Yeah, thank you Lena. Thank you Audrey. And in just a moment, I'm going to read Dr. Schmitz's full bio, but as you'll soon realize, as soon as she starts speaking, we have got a world-class expert on this topic joining us tonight. And because of just the caliber of the speaker, we decided instead of restricting this to the Pacific Region Community, we wanted to expand it to the full national nutrition and wellness chapter. So welcome to everybody joining from around the country. And like Audrey said, as myeloma patients, we have a very supportive community. We have an abundance of new treatment options, but even with that, there are some times when it feels like life can be just out of control. And like Audrey said, our exercise, our nutrition, these are things that are largely in our control. And so we're very fortunate to have Dr. Schmitz joining us and she can explain the research behind exercise oncology, give us some practical guidance, and I'm sure inspire us to get moving through cancer. So Dr. Catherine Schmitz is a distinguished professor of hematology oncology at the University of Pittsburgh. She has published over 350 scientific peer-reviewed articles, including many in top journals, such as JAMA, the New England Journal of Medicine, Journal of Clinical Oncology, and others. Dr. Schmitz has led a dozen or more exercise intervention trials in cancer populations, including the Weisser Survival Trial, the PAL Trial, the ENAK Trial, among others. She has served as president of the American College of Sports Medicine from 2017 to 2018, and during that time worked tirelessly to advance the cause of exercise oncology, including co-chairing the second ACSM roundtable on exercise and cancer prevention and control and starting the Moving Through Cancer Initiative under the auspices of the Exercise is Medicine program of ACSM. Dr. Schmitz, we are so, so happy to have you joining us tonight, and we'll turn it over to you. All right, fantastic. Thank you all so much for the opportunity to speak with you about something I care about so very much, and to have the opportunity to share about moving through cancer. So moving through cancer is a set of words that I have really triangulated around. It's the name of the initiative that I started at ACSM. It's the name of my book. It's the name of a new movie. You can find a 20-minute movie called Moving Through Cancer on YouTube for free. It is narrated by none other than Scotty Hamilton, U.S. Olympian gold medalist, and it really kind of summarizes a lot of what I'll talk about in my talk today as well, so you can go check that out. So I like to start talks to folks that are going through a cancer journey or supporting somebody through a cancer journey with the phrase, but I'm so tired, because I think that one of the things that we hear a lot when we start talking to people about trying to get them to be more physically active when they're living with and beyond cancer is, you know, what part of I'm tired do you not understand? So, why would you ask me to exercise when I'm already so tired? And I'm hoping by the end of my talk that you will have an answer for that for yourself. If I can get my slice, go forward. There we go. So this is an overview of what we're going to do tonight. I'm going to introduce you to something called Exercise Snacks. You didn't know it. This was a very sneaky way of getting you to do a workout tonight. We're going to move together, and then I'm going to talk about why you should exercise in a couple of sections. One about exercise and cancer prevention to begin with. The second is exercise to address symptoms during and after treatment. And then we'll do some, another exercise snack. And then I want to talk about some inspiration from patients and survivors, and then I'll take your questions at the end. Okay, so our first exercise snack, the idea behind an exercise snack is that think about a snack. Snack is not a meal, right? So it's a short burst of exercise that you do throughout the day. It's a one minute workout, and you can keep your camera off. That's fine with me, but we are, if you are able, I'm going to ask that you do some chair squats with me. So this is a fun-filled bite-sized exercise event. We'll do just 10 of them. I'm going to do them on screen. So I'm going to stand up and then sit back down. That's one. Stand up and sit back down. That's two. And up and down. That's three. If you're not able to do chair squats, that's okay. You can squeeze your buttocks every time I come up and down. That's five. I hope I'm counting right. Sex trainers are very, very bad at counting. Did you know that? Seven. That's why you think you have two more and they tell you you have five more. It's because they can't count. And one more and sit back down. Thank you very much. That's your first exercise snack for the evening. We're going to do three of them. So there is a field of research called epidemiology that does observational studies, but they follow people. They ask them about their physical activity and then they follow people for decades to find out whether they develop cancer or other diseases. And in these cohort studies, they have studied whether or not there is a relationship between cancer incidence and physical activity. And the most striking of the studies that I know of in this field is something called the pooled project that was put together by Dr. Steven Moore from the National Cancer Institute. And this was a study that had 1.44 million people in it from the United States, Canada, and Europe. And what they were able to show was that there is a really striking reduction in the likelihood of onset of a variety of different cancers, including multiple myeloma. You can see this here. But all of these cancers, they showed that there was a preventive effect of being more physically active versus less physically active. Now, if you are a discerning eye, you might think, yeah, but isn't that about weight? Isn't that about body mass index? Isn't that because of obesity? Because of the connection between physical activity and obesity. And so what Dr. Moore and his colleagues did was they adjusted all of their results for body mass index in order to tell you whether or not it was the result of the effects of physical activity on body habitus, on body mass index. And the answer is, no, it's really not. The only cancer for which there is a huge effect of adjusting for BMI, I hope you can see my cursor, is endometrial cancer, which is a cancer that is very, very associated with obesity. But for multiple myeloma, there is great overlap of the magnitude of the effect that we see, whether we adjust for BMI or not. And so physical activity does have an effect of reducing risk for multiple myeloma and a variety of other cancers. In the area of exercise and cancer survivorship, we also see from a variety of different systematic reviews, including one by Alka Patel from the American Cancer Society in 2019, there is somewhere between a 30 to 33% reduced risk of cancer-specific mortality for specifically breast, colon, and prostate cancer for people who are more versus less physically active. That is fantastic news. Now, does that have anything to do with multiple myeloma? We don't know because the research hasn't actually told us this. That doesn't mean there isn't an effect. It just means that we don't have the research done yet. So why? What would be the reasons? Because we can very easily understand how physical activity would be associated with heart disease. We understand that when we exercise, our hearts beat faster and it's going to change our blood pressure. There are a variety of reasons why you would think that physical activity would have to do with heart disease. Well, what does exercise have to do with cancer and the development of cancer? Well, it turns out that exercise has an effect on a variety of body systems in addition to the cardiovascular system, in addition to the musculoskeletal system that have real import for the development of cancer. We know that exercise alters immune response. It alters metabolism. It alters tumor physiology, the actual physiology of the tumors themselves. The way that the tumors behave in the body varies according to whether somebody is physically active versus not. The cell signaling cascades that lead to development of tumors or progression of tumors is altered by exercise training as well. Gene expression changes as a result of, so sorry, I don't know why it's going forward like that. I'll just keep fixing it. Gene expression is changed by exercise training and reactive oxygen species, which is the free radicals that attack and alter the milieu in which tumors are growing is actually reduced. All of those things are reduced in individuals who are more physically active. Dr. Hojman published a beautiful review in 2018 that showed that metabolic disturbance and low grade inflammation is very, very common among people who are untrained and that we see improved cytotoxic immune function, metabolic health, and improved perfusion among trained individuals. And so the figure on the right side shows the untrained, slightly overweight individual. And you can see that what we're seeing here is metabolic disturbance and low grade inflammation. And that leads to more tumor growth and the greater likelihood of metastasis. If we then start doing training, we have physical effects, we have endocrine effects that alters natural killer cell infiltration. It also reduces reactive oxygen species, induce cell damage, and reduces metastasis. The individuals who are trained have improved cytotoxic immune function and metabolic health and also have improved perfusion. What that means is that the way that blood gets to the tumors is different and better and more organized in the person who is trained. And that helps medicines to get to the tumor so that we can treat the cancer. We also have animal model data that is extremely supportive of a relationship between exercise and progression of tumors. So this is a slide that shows you the percent reduction in tumor growth of mouse tumors and immune component mice in a variety of different types of tumors. So a broad variety of types of tumors. And you can see it's anywhere from 31% to 67% reduction in tumor growth for mice that are in cages that are given wheels to run with, as opposed to mice who are not given wheels to run with in our sedentary. And then human tumors in immune incompetent mice, this is a different model for mouse model studies. And when we look at this, what we see again is a less likelihood of growth of the tumor in the mouse that is given the wheel to run with, as opposed to the mouse that is sedentary. Well, why? Why would that be occurring? There's some brilliant work that comes out of MD Anderson from the laboratory of Kerry Sepp Schadler. And what Kerry was able to show in a melanoma model, as well as in a pancreatic cancer model, what she did was she had four groups of animals. One group of animals had no exercise and no treatment with chemotherapy. And that was the black dotted line here. And then there was a group that had exercise only. And you can see the growth of the tumor was the greatest in the exercise only group. And then you can see what happened in the group that got the chemotherapy, the doxorubicin group. And then you can see what happened when we combine the chemotherapy with the exercise. And so the tumor growth over the course of 15 days in animals that are given either nothing, exercise only, chemotherapy only, or both chemotherapy and exercise. It is the chemotherapy and exercise that does the best for halting the tumor from growing. So she showed this in the melanoma model, and then she repeated the exact same finding in the pancreatic cancer model. So exercise oncology is not a field that I just thought of this weekend in my garage. This is something that has been around for a very, very long time. In fact, when I did a review of the history of the field of exercise oncology, I found that the earliest paper that I could identify was from 1911 from a Dr. Ewing in Minnesota who followed individuals who developed cancer versus those who did not develop cancer. And what he noted was that those who developed cancer were more likely to be sedentary, and the people who didn't develop cancer were more likely to be laborers and people who did things that caused them to have to work physically for their jobs. So we've known for a very long time that there was some kind of relationship between movement and cancer. The first human clinical trials in this field came in the late 1980s at Ohio State University. The first review in the area was published in 1996. I published the first meta analysis in the area in 2005. The American College of Sports Medicine published the first roundtable guidelines on exercise for cancer patients and survivors in 2010, and in 2019 we published the second roundtable guidelines for cancer patients and survivors. What you can also see from this slide is that there has been an exponential rise in the number of randomized controlled trials in the field of exercise oncology, particularly between 2010 and the present. The gain in the number of trials continues to date. If you were to search PubMed, which is where scientists go to find their colleagues' work, and you were to search for exercise and cancer and randomized controlled trials in English and in humans, what you would find is that there are over 2,600 human clinical trials that have been completed in the field of exercise oncology. So you might wonder what I've contributed to this literature. My seminal contribution in this area was the PAL trial, which was published over a decade ago in the New England Journal of Medicine and in JAMA, and what we found in the PAL trial was that contrary to the current clinical advice that was given to women at the time, that breast cancer survivors with and at risk for breast cancer-related lymphedema could do resistance training, could do slowly progressive resistance training. I'm very proud to say that we worked very diligently over the course of about a decade after the PAL trial was over to create a clinical program that now exists across the country called Strength After Breast Cancer, which is paid for by insurance and available in over 1,000 locations, and there is a continuing education credit program based on the training for this protocol that is available commercially through close training and consulting. The other thing that I can tell you based on all of the preponderance of evidence that is out there in Exercise Oncology is that guidelines have proliferated. I've talked a fair bit about the fact that the American College of Sports Medicine has published guidelines, but they're not the only ones. The American Cancer Society has also published guidelines indicating that cancer survivors should be more physically active in order to benefit their health and their well-being, and importantly, the leading institution or organization in our country for clinical oncologists, the American Society of Clinical Oncology, has also published a guideline specifically about exercise, diet, and weight management during cancer treatment, and what they conclude is that medical oncologists should, and they do use the word should, refer patients receiving chemotherapy to exercise programming to address common symptoms and side effects. As a result of all of this information, you might not be surprised to hear that we feel we can conclude a few things. Actually, we do know beyond the shadow of a doubt that exercise has a positive effect on a number of different outcomes, and the infographic that I'm referring to on this slide is available at exercisesmedicine.org, Moving Through Cancer. And so the things that we know exercise can help with include cancer-related fatigue. In fact, there is no drug on the market that is as effective as exercise for cancer-related fatigue. That's a little bit of an answer for my title of my talk, but I'm so tired. Well, it turns out that exercise is great medicine for cancer-related fatigue. We also know that exercise helps with health-related quality of life, physical function, which is your ability to carry your groceries and your ability to climb stairs and make your bed and do your laundry and play with your children or your grandchildren, anxiety and depression, sleep, breast cancer-related lymphedema, and bone health. So all of these things are made better by being more physically active. That said, there are some other outcomes for which we believe we need more research, and these include, Cardiotoxicity, Chemotherapy-induced Peripheral Neuropathy, Cognitive Function, FALSE, Nausea, Pain, Sexual Function, and Treatment Tolerance. So when we concluded from the American College of Sports Medicine Guidelines Roundtable that treatment tolerance was something we needed more research on, the National Cancer Institute responded by releasing a request for applications for research to specifically look at the effects of exercise on treatment tolerance, and they started what's called the INICDO program. INICDO stands for Exercise and Nutrition Interventions to Improve Cancer-Treatment-Related Outcomes, and I'm very proud to be the principal investigator of one of the INICDO trials, it's called Thrive 65, and we're recruiting older breast cancer patients into our trial. Okay, exercise snack number two. This one is calf raises, so I'm going to stand behind my chair, and if you can stand, that's great, if you're not able to stand, that's okay, you can do these seated. So you're going to hold on to your chair, you're going to stand behind your chair, and you're going to stand behind your chair, and you're going to stand behind your chair, and you're going to raise your heels and come back down, and two, we're going to do 10 of these, and three, and four, did you know that your calf muscles are the most important muscle in your body to help you get up and down stairs? If you lose your capacity to use your calf muscles, it means you will have a difficult time climbing stairs. So our calf muscles are vital for our function, and here we go, this is 10 and down. All right, fantastic, thank you very much. Didn't know you're getting a bonus of a workout tonight, did you? All right, so based on the fact that we have all of this beautiful evidence telling us that we should be physically active during and after our cancer journey, or during our cancer journey, you would think that it would be happening, that somehow we would translate this so that doctors would be talking about exercise, and people would know that they needed exercise, and opportunities to exercise would be easy. Unfortunately, that's not the case yet. 30 to 47 percent of cancer patients are adequately active, and what we hear is that 15 percent of patients report being referred to an exercise program by their oncologist, according to a survey done by the American Society of Clinical Oncology. This is why we started the Moving Through Cancer initiative at the American College of Sports Medicine. This was my presidential initiative the year that I was president of ACSM. It is the first disease-specific initiative underneath the umbrella of the exercises medicine program, and so what we decided to do was bring together a multidisciplinary team. What you see in this little picture here is a medical oncologist, physical medicine rehabilitation doctor, an oncology nurse, a physical therapist, some exercise physiologists, and of course my dog, very importantly my dog. This was a retreat we held in 2019 in order to answer the question, what would need to happen for exercise to become standard of care in the setting of oncology by 2029 in a decade. We published our agenda setting paper in the journal Cancer, and I commend it to you if you're interested in that kind of thing. So our agenda areas, the thing that we think is really important in order for us to make exercise a standard of care and oncology include policy changes. We need to make exercise something that is covered by third-party payers so that we have equitable distribution of exercise oncology programs across the entire country. We already have mapped exercise oncology programs in the U.S., and we know that there are health care inequities in access to exercise oncology programming according to race and ethnicity, according to socioeconomic status, and according to geography. Of course these programs are more common in urban settings than in rural settings. We also believe that we need more program development. We need programs where and when people need them. We need to make sure that we have an adequate workforce in order to meet the needs of cancer patients and survivors. We need to make people aware of the fact that exercise is useful for them as they are living with and beyond cancer, and we need more research and evaluation of the programs that do exist to make sure that what we're offering to people are really effective programs. We're really proud that one of our success stories from the Moving Through Cancer Initiative is that the National Accreditation Program for Breast Centers, which accredits over 600 different programs across the United States, has issued new standards, which recently adopted, effective just in this year, which will require breast programs to declare a plan for functional evaluations before surgery, exercise recommendations while people are under the care of a medical oncologist, and exercise referrals at the point of survivorship. We also feel, as I said, that people need programming where and when needed. What we're working on at this point is identifying the programs. We've identified 2,133 programs so far. We have a national directory, which you're welcome to go take a look at and find programming near you. We've mapped the programming. We've identified the gaps. I've mentioned a little bit of that so far. We're also doing a process called What Does Good Look Like? We're reviewing five exemplar programs from across the United States, and we'll be publishing findings to help others who might be interested in starting programs to know how to do that. We're also in the process of doing a cost analysis. We're looking at three large exercise oncology organizations, and we want people to understand how much it costs to do these kinds of programs and make that broadly available on our website so that people understand what kind of resources are needed to run these programs. This is what the map of the exercise oncology programming looks like across the United States. What you can see are black specks. Those black specks are the census tracts in the United States that have an exercise oncology program, and the red areas are the rural areas of the United States that do not have any exercise oncology programming, and the purple are the areas that are urban census tracts in the United States that do not have any access to exercise programming. You can see we have a long way to go, and we can absolutely document based on multiple logistic regression that there are disparities with regard to race, socioeconomic status, and geography with regard to access to exercise oncology. We have some real work to do. This slide concludes basically everything that I just said to you, and so we do have disparities in access to cancer rehabilitation and exercise programs, and we believe that this is likely to worsen outcomes for rural minority and lower SES populations. We know that 39% of the U.S. population lives in a census tract greater than 10 miles from exercise oncology programming, and that the distribution of the programming does vary, as I've mentioned. We have started a national exercise oncology directory, and we're hoping to update this with a triage tool. In spring 2024, the triage tool is scrolling at the bottom just to give you an idea of the kind of questions that are in the triage tool, and the idea behind this national exercise oncology directory is to try to point people to exercise oncology programming where they live, but what we also recognize is that not everybody is at the same level of function when they would approach this, and so we're updating this with a triage tool so that the person who really needs a lot of individualized attention and is not doing as well functionally is pointed to the right programming, and the person who's really doing quite well and just wants a little bit of help is pointed to the right programming as well. We also are really interested in increasing awareness. I do a lot of talks around the United States and elsewhere, and when I get into an Uber or a taxi and I tell them that I do research on exercise and cancer, I generally get sort of a quizzical look, and then the question is, well, why? What's the relationship? And my dream is that someday I'm going to get into an Uber and have somebody say, oh yeah, I heard that's a good thing. So we're really interested in making sure that everyone living with cancer is aware of the exercise benefits. We have developed a brochure with help and funding from ABBE, and we have been distributing these brochures and associated postcards in a variety of ways. We've translated the brochure into Spanish, and we are in the process of trying to evaluate current knowledge in as many populations as we can. So this is what the brochure looks like on the cover. The brochure is 17 pages long. It was developed by a multidisciplinary expert panel, and we really tried to make it as simple and easy to read as possible. Large print, few words, very appealing and very attractive coloring. We do have a QR code to get people to the National Exercise Oncology Directory. We also were very sensitive to the fact that although there are guidelines that tell us how much exercise somebody should be doing as they're going through their cancer journey, that we don't want anybody to feel intimidated by that. We want people to move. And so this caption is particularly important to us. The primary messages of the recommendations are that some movement is better than none, that movement matters. I will also note that I have published a book that has the same title as the initiative. It's called Moving Through Cancer. It is available where fine books are sold, and it is basically a guide to take you through the process of becoming and staying more physically active as you go through your cancer journey and beyond. There's also a new film available called Moving Through Cancer. It is 20 minutes long. It is narrated by U.S. Olympian Scott Hamilton, and you can find it on YouTube. If you're not able to get that link to copy it on your phone quick enough, don't worry. Just go to YouTube and search for Moving Through Cancer. What I will finish with is talking to you about what we've been doing at the UPMC Home and Cancer Center at the University of Pittsburgh in the spirit of moving through cancer. Our overall goals are very public health oriented. Our current focus is on our infusion patients, and our program is for all patients, not just the very well, not just the ones who can do a clean and jerk or take a CrossFit class. We're trying to meet patients where they are and give them appropriate recommendations given their current physical and cognitive abilities. Our overarching goal is to double the background rate of referrals. Remember that published background rate from an earlier slide is 15%. What we're doing is we're handing people the brochure that I mentioned before. We're then triaging them to appropriate exercise or rehabilitation programming, and we're making sure that we're giving them a warm handoff, that we're making sure that they're getting connected to the right programming. We start at the second chemotherapy and infusion visit. We identify those patients and the medical assistants help us with giving the patients an iPad with a validated survey for our triage tool. It's the same triage tool that we use on the website, and then we offer an intervention. The rehabilitation navigator speaks to the patient and facilitates referrals to make sure that people get to the appropriate intervention. This is the triage tool that I've mentioned before, the validated tool called Exceeds. The first question if we're doing this kind of program is whether people will actually do the triage tool. The answer is pretty much yes. 80% of patients say yes, but they will fill out the survey and they want to hear more about what we can do for them. Then there are three possible outcomes from our triage process. One outcome is that they would be triaged to community-based exercise. We refer them out to things like Live Strong at the YMCA or Cancer Bridges or community based programming in Pittsburgh. Another option is individualized program where we would bring them into our little gym in the chemo suite and give them individualized programming. Then another possibility is that they could be referred to outpatient rehabilitation programming. That would be physical therapy. Very notable findings. We are really delighted to report that after six months of doing this program, 45% of triage patients are connected to programming. Remember that background rate was 15%. Our goal was to get to 30. We got to 45. We think that this approach that we're doing, this triage approach that we're doing is a very promising way for us to try to connect patients to exercise programming during their infusion visits. I think what I've tried to outline for you very briefly is that exercise oncology in order for it to be standard of care is pretty complex. We have to have the appropriate workforce. We have to have programs where and when people need it. We need to protocolize our programs. There's a variety of things that are going to need to happen in order for us to get to the point where everybody says, oh yeah, I heard that's good for you. I am very, very, very delighted to get to work with this team, the Moving Through Cancer Task Force. It's a very multidisciplinary international team that comes together and is all working towards the goal of making exercise standard of care. But what I'd like to finish with this evening is a section of what I call What is Possible? This is Exercise Oncology in Action to tell you about a few patients that I have come across who have really inspired me and I hope will inspire you as well. The first one is Bill Jolly. He goes by Jolly. He is Jolly. Jolly had been in the US Marine Corps, but by spring of 2011, he was pretty out of shape. He was in his 40s. He had a couple of kids at home. He started trying to train for a triathlon and things didn't go well. He was wheezing very, very badly. He had a number of different encounters with medical care systems and he ended up with chest scans and they didn't really know what was going on. Eventually, another CT scan was recommended by fall of that year and he was diagnosed with stage III lymphoma. He started in January of the following year with his chemotherapy and he asked a question while he was at this major medical center, I won't name the medical center, where is the exercise program for the cancer patients? The medical oncologist who he was working with said there isn't one, but maybe call the Leukemia Lymphoma Society. He did and he started doing team and training. Five months after chemo, he did his first marathon. The next year, he did an Olympic tri. The next year, he did another Olympic tri. He did a half marathon a few years after that. He had a relapse a few years after that and started oral targeted therapy, which has a major side effect of enormous, enormous cancer related fatigue. There's a quote in here that I am actually going to read because I think it's so inspiring. I felt myself going to a dark place and I didn't like it. I didn't want to work and I didn't want to talk to my wife or kids. After four days of increasing depression by the day, I told my wife at 10.30 p.m. I had to go run. One mile into my run, my fatigue and depression just vanished. I discovered I could keep the fatigue and depression away as long as I exercised every other day. So that's really Jolly's major, major take home lesson here. And he allows me to share his story as long as I share this with you. He says, listen to your body. You will know when something's wrong before a lab test. If something feels off, don't ignore it. Be quick to get help from allied health professionals such as exercise, nutrition and psychology, medicine and surgery are not your only tools. Exercise can reduce or eliminate medication symptoms and reduce recurrence in some cancers. And exercise, this is huge. Exercise gives patients control of their lives back. And the list goes on. Sydney Hooper is a pancreatic cancer survivor, Ironman competitor. Susan Helmer, she's a three time survivor, DES daughter, also a lung cancer and pancreatic cancer survivor, master swimmer. Gabriella Grunwald had adenoid cystic carcinoma diagnosed in 2011. She was, while she dealt with her cancer, a sponsored ranked US track and field runner. She placed fourth in the 1500 in the London Olympic trials with cancer. She was the national champion in the 3000 meter in 2014 with cancer. She had a quote over her couch that said there are two ways to live your life. The first is as if nothing is a miracle. The other is as if everything is a miracle. Mike Levine, stage four pancreatic cancer patient who was told to go home and rest. He did so. His friends saw that he was wasting away and they got him back on the bike. And he did one last Ironman competition before he passed away. Keegan Randall is a US gold medal Olympian from cross country skiing who had stage three breast cancer. And, you know, she basically used her training as an athlete to help her get through her treatment process. And her story is in my book in chapter 16, as are many of the others that I have talked about tonight. So what I would submit to you all is that it's time for a paradigm shift. Exercise is medicine for people living with and beyond cancer. And really a little bit goes a long way. Thank you very much for your attention. I'm going to stop sharing slides so that we can have a discussion. Wonderful, Dr. Schmitz. Thank you so much. I really enjoyed that presentation. Especially those inspiring stories at the end. I invite our audience to enter their questions into the Q&A that you'll see near the bottom of your screen. And we'll get to those. I see a couple questions submitted already. I have some questions of my own. Before we get into that, I just wanted to briefly turn the time over to Todd. Todd mentioned that there's, when we were discussing earlier, Dr. Schmitz, about myeloma-specific studies when it comes to exercise. I did appreciate that in some of those studies, they did look at myeloma as well that you shared. It's always helpful to be included. But Todd just wanted to briefly turn the time over to you to share quickly about that myeloma-specific study. Yes, two pages of notes. Oh my God. I had to take my camera off for two reasons. One, because I looked silly in that snack exercise drill. But we did them. We did them all. And two, if I had taken my shirt off, I would look like Bill Jolly in your example there, the before picture. Come back in a year. But come back in a year. And three, I had to turn it off because I was so choked up at numerous times. Because what you've just outlined is so important and it's something that we can do. I think when you look at, you said 2,600 human trials and exercise oncology. And your conclusion with that was there's a benefit, beyond a benefit of a doubt. I think it's so, so simple. And I think, I know you've inspired me and Diane to get serious. And I'm so grateful for that. And I'm so grateful for that. I think, as Audrey said, there's the research in myeloma as well. The 2,600, I think, says enough. But in myeloma, you even pointed to some studies. There was study presented at ASCO. As myeloma patients, we do spend a lot of time focused on T cell health. We need strong immune systems. T cells are really important that they're not exhausted. And there was studies done at Roswell Park by Dr. Jens Hillegas, one of my myeloma heroes. He is for many of you. And he showed that with exercise, you can decrease the exhaustion of your T cells. Just one more bit of evidence on top of the 2,600 trials that Dr. Schmitz outlined. And for me, it was a call to action these last 40 minutes with you to get serious and and to look at the simple steps we can do, whether they're acts, whether they're snacks, or whether it's the combination of aerobic and resistance training. But I loved your call to action regarding helping our community incorporate exercise oncology as a standard of care. And one thing I've been so proud about working with Health Tree is how empowered and how much of an advocacy there can be coming from the patients themselves. Like you mentioned in one of your case studies, the patient saying, where is your exercise oncology program? And asking that to our cancer centers. That's one of the takeaways I've got is going back to our center and saying, we need to do better. And so my question, I'll start it off with a question is, what's the best way to do that to really challenge your center? Is it to take that exercise prescription template? Is it the brochure? How would we help you make it so that when we get in an Uber and say, exercise and oncology, more people know? How can we do that? Not only personally, but we can get our our care teams to be pushing that forward. Yeah, I think you need to, I think if you all as patients, you know, breast cancer is kind of the 800 pound gorilla, right? Because there's so many of them. And, you know, quarter of a million every year diagnosed and, you know, four million survivors. And, you know, when they, you know, speak, their, their, their physicians are listening. And when you all speak, your physicians are listening. So if you go in and say, I demand, tell me, I mean, honestly, I defy you to find another supportive care intervention that has as much evidence as exercise does. Go, go find it. If you find it, come tell me about it. Because I'd like to know, you know, maybe I'll work on that. But I don't think you're going to find anything. So why are we not doing this? And the answer is because logistically, it's not easy for them. It's easy for them to hand you a pill. But it's not logistically easy for them to create an exercise program. And so we have to help them to figure out how to do that. And I think there are a variety of answers to that. I think telehealth programming is a possibility. But I think if you go in and demand that there be some kind of programming, I think that that will go a very long way. You can ask them to invite me to give a talk. I give a lot of talks because this is important to me. You know, awareness, I give, I give so many talks that I'm giving for the express purpose of people saying, is why is this different than PT? There's a question actually in the chat. Is this different than PT? Yes, this is different than PT. So I will explain why. So physical therapy and cancer rehabilitation is extremely important. It's very impairment based. And so the idea behind going to a physical therapist is that if you have a specific impairment that precludes you from being able to function in basic activities of daily living, like being able to walk, then you go to a physical therapist and they treat it. And they might treat it with heat. They might treat it with EMG. They might treat it with massage. They might treat it with a variety of different things. They might treat it with movement. They might treat it with some exercise. So exercise is one thing in the arsenal for physical therapy, but is not the only thing that they use. The problem is that they, you run out of your insurance for cancer rehabilitation before you are better. And so what we are now making the argument for, I'm answering another question from the chat here, is we are actually putting forward a national coverage determination application to the Centers for Medicare Services in the coming months in order to get a determination so that we get third party care coverage for exercise oncology services, which we think will go a long way to erasing the inequities in access to exercise oncology. Awesome. Thank you. And thank you for being proactive about looking at the chat and answering those questions. For the audience's context, you should be able to see those questions under answered if you have any further questions about the questions. Thank you again, Dr. Smits. I also had the question about what we can do to raise awareness. I really do think that patients and caregivers' voices are very powerful when it comes to this and encourage the audience to do exactly as you said. I loved the part in your presentation where you talked about that some movement is better than none. Yes. That being said, the snack activities were so great. Do you have a recommendation of how many snack activities or even a list of recommended snack activities where people could get started if they're coming off of the couch or after a system cell transplant? Yes. Yes, I do. So I actually organized my book around five exercises. I tried to keep it. The idea behind the book is that there's actually a UK-based surgeon who is also a cancer survivor, cancer patient at this point. She's got recurrent cancer. Her name is Liz O'Riordan. I interviewed her in the process of writing the book. She said something that just really stuck with me. She said, this is a surgeon. This is somebody who's highly educated. She said, hey, there were days when I was going through treatment when I couldn't remember how to spell the word potato. I wrote the book for that person. The book was written so that if you were in the middle of a lot of onslaught of dealing with the intensity of what it is to be dealing with cancer, that it's still digestible and usable. There are five exercises that are recommended. We just keep repeating them. There's a lot of repetition in the book on purpose in order to make it very, very plain and very clear. The other thing is that there is a website associated with the book. The website has videos of all of the exercises plus a few more. I would commend those. One of the things I think is most important for me to say is that there is not an exercise that is the right exercise. The right exercise is the one that means you're not sitting on the couch. That's the most important thing is that you are getting off the couch and moving. Nobody benefits from sitting on the couch all day. I don't care how sick you are. No one benefits from sitting on the couch all day. Thank you for that answer. For our audience, we'll include the link to that YouTube video that you've been referencing to your website and to your book in our follow-up email and perhaps a copy of your slides if you do feel comfortable sharing those documents of no pressure. We want to make sure that with the recording, they also get these resources so they don't just think, oh, that's really nice information, but now what can I do due to that information? I see a couple of questions here that I just wanted to quickly address myself. If you have any thoughts, Dr. Schmitz, you're welcome to add to it. Great questions, honestly, about could it be possible to slow progression through exercise oncology? Could it be possible to extend length of remission through exercise oncology? To be frank, in the world of multiple myeloma, this research is still in its very, very early phases. The good news is you're not the only ones asking these questions. The more that we ask, the more doctors and specialists and researchers are going to be willing and funded, quite frankly, to look into these things. We don't have those answers yet, but those are good answers. I mean, good questions. And through nutrition and through fitness, how can we affect our own progression and remission? Any other thoughts you wanted to share there, Dr. Schmitz? Yeah, I think multiple myeloma is such a use case, if you will, for the loss of control issue. It just feels like such an example of that because, as Todd mentioned earlier in our conversation, it's not something that you don't go into remission. You're never without it. And so what can you do? Can I guarantee that an exercise program and eating well will reduce the likelihood of smoldering myeloma to progress? Nope. But what I can guarantee is that your capacity to withstand treatments that are thrown at you will be better. If you are in fighting shape. And that's what I know exercise can do for every myeloma patient. And in addition, Dr. Schmitz, they'll qualify for more treatments. We do a lot of studies now about frailty and frailty scores. And age actually doesn't matter. It just matters your ability to be physically fit. Honestly. So one of the really cool findings recently that I've been very interested in is there are these things called epigenetic clocks that help us to understand the difference between your chronological age and your biological age. And what matters, what you're getting at, Audrey, is your biological age. And one of the things that we can show over and over again is that exercise reverses the biological age. We actually can reverse it through exercise and nutrition. And with that in mind, then you want to be, you want to have the lowest possible biological age as you're going through any kind of arduous cancer treatment. So that probably is more compelling evidence than anything else I could say. Yeah, I agree. Thank you. My final question. We've talked a lot about movement and how it can benefit us. I do worry that some patients are going to take this to the bank and overwork themselves and then cause more problems. Sure. Because I love them, right? But how do you find the balance between being super motivated and wanting to work out, move, and prioritizing rest because rest is also important? Right. So exercise can be overdone. And so that is a worry. I will tell you, Audrey, that the people that I worry about most in exercise oncology are the people who used to be athletes because they have the muscle memory to be able to push themselves and they have the capacity because they're used to what it feels like to work hard. They can push themselves too much, too hard, and really hurt themselves as they're going through their cancer journey. So if somebody has been an athlete in the past, then I have extra, you know, I actually write about this in my book. There's sort of extra caution of you guys are the ones I'm worried about. Please slow down. What I find, Audrey, is that most people who do not have an athletic background won't push themselves that hard. There are exceptions to that. I will say that exercise progression should be gradual. If you are currently sedentary, the right amount of exercise for you is 10 minutes walking a day. And if you get to the end of the week and you're like, that was easy, then go to 15. It won't take you that many weeks to get to 30 minutes a day, and that's a good amount of exercise. With resistance training, you know, start with a couple of exercises two times a week and start increasing the resistance after about two or three weeks. Very helpful. Thank you. And I think you can talk to your doctor too if you have these questions, especially if you're newly diagnosed, you might have bone involvement as a myeloma patient. You can ask your doctor before starting a real rigorous exercise program. But what you're suggesting too is you could start moving as soon as we're done with this call if you haven't today. In fact, my watch actually said you've been sitting for a while. You really start moving. I'm like, oh my gosh, that's so ironic that it just said that. That's great. Dr. Smith, you had in your book, you give so many practical tips, you had said you mentioned the 10 minute rule. Yes. Can you, I just, that one really resonated with me. It made me laugh. Diane tells me all the time. Let's just see how you're doing after 10 minutes. Yes, exactly. This is kind of an industry standard in exercise oncology and practice. And that is that if you're not sure whether you are able to exercise today, if you're feeling, my mother would call it punk. If you're feeling punk, you can get my gist. If you're feeling punk and you're not sure, I don't know if I can do this today, then you get off the couch and you move for 10 minutes and you can just stand and sway. You can just walk around, walk up and down the stairs, whatever, dance to music, walk around the block, whatever it is that you can do for 10 minutes. And honest to God, really, really ask yourself at the end of the 10 minutes, do I feel worse? Do I feel the same or do I feel better? And unless you feel worse, keep moving. Awesome. Very simple. Unfortunately, we're not able to answer all questions tonight, but I did want to finish with Jennifer's comment because it's very impactful and I'm sure other people feel the same. She says, I walked regularly previously, especially prior to COVID and diagnosed during COVID. I had major back surgery in June, but this inspired me. Somebody cares. Thank you for caring. Thank you. And I think this is why the events are just so important because we do care. And Dr. Schmitz, you've dedicated your life to caring about this and we're so grateful to you. We're grateful for our audience who showed up tonight. Maybe they're watching the recording. Movement matters. And I think that's what we're coming out of this session having been either reminded or we learned it or we're just ready to do it. And so thank you, Dr. Schmitz for taking the time. I'm going to finish with a couple of outro announcements, but is there anything that you want to say before you leave us tonight, Dr. Schmitz? Thank you so much for the opportunity. I care so much about this topic and I really appreciate the opportunity to talk to you. Yeah, we are just so grateful. Moving through cancer. Moving through cancer. Wonderful. Thank you again, Dr. Schmitz. That was wonderful. Dr. Schmitz, you're free to go. I'll be in touch with you just to thank you and send you a little something. So thank you very much. All right. Thanks. Good night, everybody. To my audience, I'm just going to do a couple more outro announcements and then I'll let you go. Thank you again for taking the time to be here. Our next event will be on March 21st. We're going to be hearing from Dr. Betsy O'Donnell and she is an amazing physician who has really dedicated her work in myeloma to lifestyle medicine and figuring out how lifestyle medicine can improve your life. So it's kind of a continuation, but lifestyle medicine includes exercise and more. So join us in March as we continue this conversation on how we can take control of our myeloma journeys, whether we're a caregiver or a patient, and make sure that we are living the highest quality of life possible because we all deserve that. A quick reminder to take the survey as you leave the session today. Zoom will prompt you to take it. It takes one to two minutes. Tell us what you liked about today, what we can do better next time, and future topic suggestions that you have for us. Other events that are upcoming you may be interested in on Thursday, the 22nd, we have our Black Myeloma Health Community Panel. This is an annual event that we do. We have three amazing specialists coming to talk about the hope for the future of Black Myeloma to celebrate Black History Month. Then on the 27th, we have our Plasma Cell Leukemia Chapter. Dr. Sporov from the Huntsman Cancer Institute is going to be sharing about one of his recent plasma cell leukemia trials. And then on the leap year day, the extra day that the world gives us every four years, we're doing our Amyloidosis Community Chapter, which is the role of stem cell transplant and amyloidosis with Dr. Efeber. So to sign up for any of those events and even more events I haven't mentioned, you can click the link at the bottom of the slide or it will be included in our follow-up email. Thank you to Regeneron, Sanofi, Janssen Oncology, GSK, and Bristol Myers Squibb. Thank you to Todd and Diane for participating in tonight and making this speaker possible. And a big thank you to all of you for just spending the night with us. We hope you have a great rest of your night and that you stay moving and also rest at the same time. All right everyone, take care. Bye-bye.