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									Exercise Program


       Developed by
                     Wonder Drug
•   40-70% cancer incidence; 50% survival
•   50% CAD events & 31% mortality post MI
•   30% reduction in strokes
•   B.P. control
•   Diabetes: 58% reduction in incidence and effective
    Rx for D.M.
                      Dementia = 40%
•   Brain Fx:         Cognitive Fx: BDNF+ BF to Hippocampus
•   Arthritis: Degenerative joint disease
•   47% remission in depression (drugs=42% drugs)
•   Life expectancy    2 Hrs. per 1 Hr. vigorous exer.
     TV time & Life Expectancy
Australian study: 11,000 patients 25y/o &
older followed 9 years (1999-2008)
• In 2008 participants watched 9.8 billion hrs.
of TV = loss of 286,000 life yrs. or 22’’ life lost
for every hour of TV watched after 25y/o
Taiwan Study: 416,000 individuals followed 12
yrs; walking 15”/ day added 3 years to life
compared to inactive individuals. Applied to all
age groups (20y/o - >60y/o)
                           STUDIES
                                    BREAST
Holmes; JAMA, May 25,2005; Breast Stg. I-III, 3000 patients - 8 year F/U: 3-5
hrs./wk @ ave. pace – 2.5mph; improved survival 50% (Stg. III, ER-PR +)
Melinda Irwin; HEAL study: JCO Aug 2008: 933 pts; 6 yr. f/u; 64% risk of
death from all causes with modest exercise.
                                     COLON
Meyerhardt: JCO Aug. 2006; 832 pts. Stg. III colon cancer 3.8 yr F/U: 6
hrs/wk. @ ave. pace improved survival 50%
                                    PROSTATE
Giovannucci, M.D. et. al (Harvard School of Public Health) Physical Activity
and Incident and Fatal Prostate Cancer. Arch Intern Med, May 2005; Health
Professionals Study; 47,620 males followed 14 years; 3 hours of vigorous
activity/wk- running, jogging, biking, swimming, tennis, wt. training; 70 % risk
reduction in high grade, advanced, or fatal prostate ca.
Sartor, 2010 GUCS; New ChemoRX prolongs Survival in Prostate Cancer;
carbazitaxel compared with mitoxantrone, 755 men followed a mean of 12.8
mo., increased median survival by 3 months. Significant neutropenia in 81%
              Standard of Care?
• ACSM panel of experts provided guidelines for
  exercise of cancer patients 2010
• ASCO recommended exercise during and following
  cancer treatment June 2010
• ACS Nutrition and Physical Activity Guidelines for
  Cancer Survivors May 2012
• Individuals > 65y/o represent over 6 million
  cancer survivors. Only 7% meet guidelines of
  30’’ of moderate exercise most days of the
  week.
• 13.8 million cancer survivors! WHERE IS EXERCISE?
    Human Genome & Disease (C)


• Body~30 trillion cells
• Cells divide 10,000. trillion X in lifetime
• Apoptosis-orderly-programmed cell
  death
• Mutation-renegade cell produces cancer
       Oncogenes
       Suppressor genes
       Exercise/genome/cancer
• 3 hrs of exercise/wk up-regulates tumor
  suppressor genes BRACA1 &2
• “Tones down” tumor promoter
  genes(oncogenes).
• Modulates cell cycle and DNA repair
  pathways.
• Exercise produces gene modification
  increasing HDL cholesterol
      Physiologic Effects of Exercise
• Insulin Like Growth Factor (IGF)
• Inflammation
    – Cytokines (TNF)
    – C- reactive protein
•   Immune stimulation
•   Estrogen production
•   Androgen production
•   Cholesterol, triglycerides, LDL, HDL
•   Fat      aromatase: converts androgens to
    estrogen
                 ACUTE BENEFITS
• Chemotherapy toxicity
  1.   Fatigue
  2.   Cardiac
  3.   Nausea & vomiting
  4.   Neuropathy
• Chemotherapy efficacy       Dose intensity
                              Chemo completion
                              Tumor perfusion
• Improves coexisting co-morbid disease
• Bone & muscle loss (balance/falls) independence
• Mood/Depression: victim vs. survivor (QOL)
              CHRONIC BENEFITS
•   Fatigue – CFS >70% - lasts 5 years
•   Lymphedema - Post mastectomy issues
•   Cardiac toxicity- cardio-oncology
•   Osteoporosis
•   Weight gain
•   Depression/self esteem/happiness (QOL)
•   Cognitive function
•   SURVIVAL (breast, colon, prostate, ovarian)
•   CO-MORBID diseases
•   2nd cancers
   FitSTEPS for Life® 2004-2011
1. Over 12,000 patients referred to 14
   facilities in Dallas & East Texas
   1.Wellness centers
   2. Cancer clinics
   3. Hospital oncology floor
   4. Churches
• Over 300,0000 visits to FSFL facilities
• 890 physicians have referred patients
• >170 oncologists
               FitSTEPS for Life®
• All patients physician referred
• Eligibility criteria
                                    In Center
• Exercise components               Home based
• Individualized/structured
                                   Physical Fitness
• Staff/administration             Psychological readiness
                                   Monitored metrics
• Duration of participation
• Provided without charge
• Data collection          Customized
                           Internet based/universal access
 I pad                    HIPPA compliant
                            Research resource
   computer
       Physician Motivation
• 2% entered cardiac rehab if not
  mentioned or modestly supported by M.D.
• 66% entered cardiac rehab. if
  recommendation was moderate -strong
  by M.D.
• 82% cancer patients prefer physician
  initiate discussion and recommendation
  of exercise as component of Rx
NAVIGATOR
          Exercise Components
            Easily Mastered
• Aerobic: Treadmill, elliptical, no seated
  aerobic equipment
• Muscle strengthening
   Core training: stability ball, seated squat
   Stretch band, dumbbells
• Flexibility
• Monitored metrics: Pulse ox., BP, HR & HRR
• Group sessions: Pilates/stability ball
                       Medical Outcomes Survey Short Form(SF-36&SF-8)

Concept/ Subscale         Low                                       High

Physical Functioning      Limited a lot if performing physical      Performs all types of physical
                          activities (bathing, dressing)            activities, including vigorous


Role-Physical             Problems with work or daily activities    No problems with work or daily
                          due to physical health                    activities due to physical health


Bodily Pain               Severe and limiting pain                  No limitations due to pain

General Health            Evaluates personal health as poor         Evaluates personal health as
                          and believes it will get worse            excellent


Vitality                  Tired and worn out all the time           Full of energy

Social Functioning        Interference with social activities due   Normal social activities
                          to physical or emotional problems


Role-Emotional            Problems with daily activities as a       No problems with daily activities
                          result of emotional problems


Mental Health             Feelings of nervousness, depression       Feelings of peace, happiness,
                                                                    calmness
• Co-morbidities (68%):
 –Heart disease (12%)
 –Lung disease (9%)
 –HTN (45%)
 –Diabetes (16%)
 –Arthritis (31%)

• Require assistive device for mobility (9%)
• Use O2 (3%)
         Disease             Stage       Current Cancer
                                             Status
Breast         (51%)   I        (20%)   Active (36%)
                                        Disease
Lung           (6%)    II       (20%)   Cured / (64%)
                                        Remission
Prostate       (6%)    III      (16%)
Colorectal     (7%)    IV       (13%)
Lymphoma       (7%)    Unknown (31%)
Other          (23%)
         Radiation               Chemotherapy
      (48% Received)            (60% Received)

Current           (19%)   Current           (40%)
1-3 months ago    (12%)   I1-3 months ago        (17%)
3-12 months ago   (17%)   3-12 months ago        (10%)
> 1 year ago      (52%)   > 1 year ago      (33%)
 Mental Health (multiple responses)
(n=701, 601, 419, 274, 207, 121, 70)
 Role Emotional (multiple responses)
(n=701, 601, 419, 274, 207, 121, 70)
Social Functioning (multiple responses)
 (n=701, 601, 419, 274, 207, 121, 70)
    Vitality (multiple responses)
(n=701, 601, 419, 274, 207, 121, 70)
General Health (multiple responses)
 (n=701, 601, 419, 274, 207, 121,
                70)
   Bodily Pain (multiple responses)
(n=701, 601, 419, 274, 207, 121, 70)
Role Physical (multiple responses)
(n=701, 601, 419, 274, 207, 121,
               70)
  Physical Functioning (multiple
            responses)
(n=701, 601, 419, 274, 207, 121, 70)
                Bottom Line
• Participants who remain in the program report
  statistically significant improvement over time
  in all eight SF-36 subscales (publication)
• The CFFL FitSTEPS Program makes a positive
  difference by the third month of participation
  and the difference is sustainable over time
• SF-8 demonstrates statistically significant
  improvement in subscales - Mental & Physical
  health in one month
           Exercise Guidelines
• Moderate intensity aerobic exercise (walking,
  jogging, dancing, swimming) 30’’ most days of
  week for a total of 150’’ moderate intensity
  (+talk/-sing)
• 75’’ a week of vigorous intensity(only speak a
  few words between breaths)
• Equivalent combination of moderate-intense
• Exercise prescription for cancer patient?
    Obstacles of Exercise Intervention
• No reimbursement for cancer rehab.
• Illusion that rest heals
• Cultural sedentary lifestyle
• attitude: physician “heal me” rather than
  “heal thyself.”
• Lack of education/motivation of pts. by M.D.
• Fractionation/complexity of health care
  delivery – universally recognized “standard of
  care” program that is safe and effective for
  all patients regardless of complexity of disease
  or magnitude of disability.

								
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