Making Every Step Count: The Role of Exercise and Cancer

[0:00:00] Dr. Diane:  Cancer diagnosis does not generally inspire a person to run to the gym and work out. But recent research is telling us movement and fitness have some real benefits while battling the disease, and maybe even in preventing it in the first place. Let's get into it. Hello, I'm Dr. Diane Reidy-Lagunes from Memorial Sloan Kettering Cancer Center, and welcome to Cancer Straight Talk. We're bringing together national experts and patients fighting these diseases to have straightforward, evidence-based conversations. Our mission is to educate and empower you and your family members to make the right decisions and live happier, healthier lives. For more information about the topics discussed here or to send your questions, please visit us at mskcc.org/podcast. Today I am thrilled and honored to have on the show Dr. Lee Jones and Charlie Sweeney to talk about the role of physical activity and the cancer patient. I've been so excited for this day because both of my guests have made an indelible mark on me as a person and a doc. They're both passionate people that have given a gift to inspire others. Dr. Lee Jones runs an exercise laboratory at MSK. That's Memorial Sloan Kettering Cancer Center, Lee's an exercise scientist and has two aspects to his research program. The first is how to prevent long term complications of therapies that might be curative, for example, potentially harmful to our heart. And the second is to study the role of exercise that actually could help treat cancer. He does so by defining doses, intensity and the cadence of that exercise program and to see if such an exercise prescription if you will, can be defined to help improve responses to chemotherapy treatments. Our second guest Charlie Sweeney, is a 50 year old dad who's about to get married in a couple of months, who looks 20 years younger than his stated age. An avid runner and is my dear patient. And now Charlie is not your average fit guy. He's a frequent marathon runner, skier and athlete, yet the conversation today is for all patients. Even if you've never stepped into a gym, Charlie was diagnosed with stage four colon cancer in March of 2018. Always fit healthy and positive. He's done everything right in life. At 50 that's the time we're supposed to get colonoscopy screenings because the average age of diagnosis is actually 65. So, there's nothing he did or didn't do to get this devastating problem. But Charlie fights this disease, and he runs. And today, Charlie shares his story with us. So, both Lee and Charlie, welcome to the show.

[0:02:28] Charlie:  Thank you.

[0:02:29] Dr. Lee:  Thank you. Great to be here.

[0:02:29] Dr. Diane:  I'd like to start with Charlie. Charlie, can you just tell us a little bit about yourself and the journey since you've been diagnosed with colon cancer?

[0:02:35] Charlie:  Sure. Thanks so much for having me. I'm excited to be here. As you mentioned, I’m a 50 year old father of two, I've got a daughter Caitlin 20. Just about to turn 23, Patrick's 21, engaged to be married to my fiancee, Kendra Packard on September 14^th of this year, so very excited about that. As Dr. Reidy mentioned, I was diagnosed with stage four colorectal cancer back in March of 2018. Important to note, there weren't any long perpetuating symptoms I was dealing with and wasn't something that in retrospect, I had ignored for a period of time, but rather, the symptoms came along very quickly. It was a month maybe in advance of seeing an upper GI or I guess the GI doc. And ultimately, a colonoscopy was scheduled, I was still 49 at the time so and they had yet to reduce the age from 50 to 49. I was still 50 at the time, and otherwise in very good health, my annual doctor visits and had no issues worth speaking of it at all. The colonoscopy quickly identified a significant tumor in the colon. I was quick to act obviously and then was fortunate enough to be put in front of some of the great doctors in the world, including Dr. Reidy and Dr. Weiser on whatever that was the Friday after being diagnosed on a Tuesday. So, once diagnosed, my treatment began very quickly. And that was yeah, the middle part of March of last year, you know, throughout my first line chemotherapy of Folfirinox where the symptoms were severe, significant nausea and fatigue and all of the wonderful things that go along with chemotherapy treatment. I found it to be heavy symptoms in the short term meaning a day or two post treatment, but was able to get back to some normal activity in the days thereafter. So T plus three, if you will, after treatment. And I quickly really kind of attached myself to the importance and the benefits of cardiovascular and just getting my heart rate going post treatment. It felt almost as if I could feel the treatments circulating through my body in those days after, after coming out of a very kind of stagnant period for a couple of days. So it didn't take long to really kind of mentally push myself to that point where a couple of days after treatment, and to this day, I've been very religious about my workout routines.

[0:04:46] Dr. Diane:  So it's very powerful because Folfirinox, as you said, is a pretty intense chemotherapy regimen. We use it only in patients that are healthy enough to receive and many patients are down and out for the entire time. But what it sounds like is that you actually gave yourself a couple of days. And then when you felt up for it, you're like, I could try this. And did you actually think it could help alleviate some of the side effects of the treatment?

[0:05:06] Charlie:  Yeah, I really did. And to your point, there was a couple of days, the day of treatment, and the two days after was what I found to be, that wouldn't have even have been an option. So it was important to kind of listen to my body and, and rest when rest was needed. But the rejuvenating effect I felt of whether it was running, spin, yoga, standard gym workout, just getting the heart rate going and getting the blood pumping through the system. I really felt as though was helping the efficacy and certainly the mental component for me was really important.

[0:05:34] Dr. Diane:  Did they actually help some of the side effects of the treatment too, some of the fatigue maybe or not-

[0:05:37] Charlie:  I do yeah. I do. I mean, I felt as I would finish workouts and continue in the days after my symptoms would really fade. So the treatment and then a couple of days thereafter would be when I would feel it and then given the next three days or a week removed, I would feel almost 100% again.

[0:05:51] Dr. Diane:  Fantastic, so incredibly important to listen to your body when you felt like you're ready you went for it and when you weren't, you kind of relaxed to hang out on the couch. So, Lee this is a game changer? No. I mean, historically, doc's got a diagnosis of cancer and we put patients to the couch or to the bed. So, could you share a little bit about what you think about this and what you do in the lab. I mean, here at Memorial, it takes a village. And so our mission is to cure cancer, we're treating our patients, but we're also trying to understand on the research side, all these different aspects of how to improve our outcome. So can you talk to us a little bit about the sort of revolution or transformation of exercise oncology?

[0:06:24] Dr. Lee:  Sure. I mean, first of all, Charlie's story is remarkable. And he's living our research. So, it's great and an honor to be sitting here listening to someone who's really doing everything we believe in. So, the history of exercise oncology that we call it probably started about 20 years ago, which really, in the research realm is not very long at all, not very long at all. So, this is when I was in my PhD in Canada. And at that time, there was really no studies that looked at the role of exercise in patients with cancer. Compare this to things like heart disease and diabetes and respiratory diseases where there's been 50 years of research looking at the role of exercise and exercise is, if you will the first line therapy for individuals who are diagnosed with these various chronic conditions yet in oncology, although they share some of the same risk factors exercise wasn't even mentioned. And I think to your point, was actually the opposite advice from oncologist and nothing against oncologist but was actually to rest and take it easy. And so from a physiologic perspective, when we when we first got into this field, I believe that's quite possibly the worst advice you can give to anybody we know the detrimental side effects of deconditioning if you're on bedrest, and if you do nothing, so at the very least, we thought we should try and get patients to try maintain their exercise levels as much as possible prior to diagnosis. And for those who are not exercising at all, could we use that as an opportunity to really educate and inform on the potential benefits of exercise? Of course back in the day, there wasn't any research evidences yes, that it was even feasible, tolerable or beneficial. So, we, and I say we that was my advisor, and quite a few of us up in Canada started some of the first research studies really looking at the safety and feasibility of exercise in individuals who've completed treatment. And those turned out pretty well. And I can remember the first conversations with an oncologist trying to convince them that exercise could be beneficial and they were like, “Lee, you can't exercise people with cancer, do you know?” I'm like, “I do, we don't really know what's out there. But given the potential benefits, and all these other conditions, and many of the symptoms and side effects are similar, we think it can be really beneficial.” So that was a bit of a struggle. But ironically, it's exactly the same conversation people will have in 70 years ago, when individuals were diagnosed with heart attacks. At that time, it was bedrest for six weeks. And now if you have a heart attack, surgery, you're exercising the day after your surgery. So, in many respects, oncology was 50 years behind where cardiology was. So, we did some of the first studies they turned out pretty well. Turns out that not only individuals want this information, but were very keen to exercise and I think probably you know better than all of us that individuals would come to you and ask you, “What should I be doing? Can I exercise? If so how much? How often? How hard? What should I be eating?” So the patient response to our studies was phenomenal. And it quickly grew from there. So and then the field really now over the past 20 years or so was really blossomed. There's research going on all over the planet in many different areas, not just breast cancer, but colorectal cancer, prostate cancer in hematologic malignancies. It's really a field that's grown incredibly well, and I think continues to grow really strongly, because there's so many questions to address, but we've got a long way to go. But I think we've come a long way over the past 20 years. And it's really encouraging. I mean, to hear these stories to know that people are out there doing this, and it's having benefits that's obviously very pleasing.

[0:09:43] Dr. Diane:  Fantastic, so, we know some of the benefits. I mean, I think the most obvious would be, could make you feel better. We know that those are different types of hormones that we're still creating to get the adrenaline going, could potentially help fatigue, but do we have data yet to share that it could for example, affect the immune system or affect the role for example, in the pre-op setting, or post-op setting, or after what we call agilent treatment, which is chemo after surgery, are those studies ongoing or do we have some data already to actually suggest that it's having a benefit?

[0:10:16] Dr. Lee:  Yeah, I think we do. And I don't think it's where it probably needs to be. But it's definitely -- I would say it's emerging for sure. And so the field really started looking, as you said, looking at really the role of exercise to help, I would say control and mitigate the symptoms and side effects of treatment, initially in individuals who have completed treatment, so I think many oncologists would say it takes a year a few years to get back to where you were. And so, we are interested in is that actually true? And so from some physiological studies, we find out that there's kind of the residual side effects of therapy that can take many years so. So, really, the data first started looking at the symptoms and side effects initially, again, following treatment to help individuals to get back to where they were before their diagnosis. And of course, that's all still in a treatment paradigm. So, what we want to do then is bring it a little bit sooner, is could we then start exercising individuals during their treatment to prevent these symptoms and side effects in the first place. And then now the researchers, can we now take that even earlier and start to exercise people right at the point of diagnosis, if you will, to try and buffer them before they start their therapy. And there's a limited window of opportunity to do those kind of things. But so I would say that the data is relatively strong, certainly in survivors in post treatment, individuals who finished their treatment, I think during treatment, there's been a lot of studies as well, and showing that it can be beneficial and certainly tolerable, maybe not for everybody, but certainly for individuals who participated in these studies. I think what your question about the immune system was getting at was, we really think about exercise as a form of treatment itself. So in heart disease and diabetes, it's not just to control the symptoms and side effects of the treatment is actually treatment for the disease. And so we think about that in the same respect in oncology. And so, we are finding out that of course, exercise can affect many different biological functions in the body, whether it's immune, whether its metabolism, whether it's levels of hormones, oxidative damage, all these other parameters that are incredibly important in both the initiation of cancer, but also the progression of cancer. So we're really trying to understand how exercise if you will, modifies the body to then convert the body into [indiscernible] [12:23] make a really hostile environment for cancer cells to live. And we know we can take individuals who have been sedentary for many years and start them training on a pretty structured and personalized exercise prescription. But we can see these remarkable changes in physiology over a relatively short period of time. Well, the studies that we're doing now are now seeing all these changes in the body. Now, how are they affecting cells that live within these specific micro environments, whether that's in the colon, whether it's in the breast, whether it's in the bone, all these organs where these cancer cells love to hang out. We know a lot about how exercise changes the heart and skeletal muscle, we know nothing about how it can change things like liver, colon, prostate, brain, lung, all these organs, again, where these cancer cells hang out. So, I think we're at a very exciting time when we're doing some of these first studies where we're looking at the biological changes in the organ of interest in both before and after exercise training, which has relevance, of course for oncology, but I think has relevance for a lot of other age related diseases. So, I think we're in a very cool time right now, one of the reasons I moved to Memorial Sloan Kettering is to answer these types of questions to work with the best people like yourself. So, I think we're poised to make some pretty amazing discoveries, because I think people like Charlie would ask, you know, I feel better, what is happening, what is happening underneath the surface? And are we potentially preventing the disease coming back or slowing it down? I think that's the key question that we want to address.

[0:13:51] Dr. Diane:  Absolutely. And I think, although we may not yet know the underlying mechanisms to which it's improving, we do have these observational studies that show in general, patients that exercise regularly certainly after their surgical resection, for example, have a remarkably at least in colon cancer, for example, 50% decrease in the chance of it coming back if they exercise regularly. Now, again, is that cause and effect some of that is what we call selection bias, these patients may be healthier to begin with. But although we haven't yet defined what mechanisms may have gotten there, the data is quite powerful and looking at the patients that have these very active lifestyles and in both colon cancer, ovarian cancer and breast cancer and showing a decreased risk of recurrence, which is very compelling.

[0:14:34] Dr. Lee:  I would say that's step number one, this observational data. Now that comes with a little bit of a pinch of salt, because again, it's individuals who might have been exercising already and they might be doing other things in their lives that also have beneficial impacts-

[0:14:46] Dr. Diane:   Early detection.

[0:14:47] Dr. Lee:  Early detection, maybe not smoking as much not drinking as much maybe healthier diet. So exercise is a cluster behavior, if you will, but for me, it's encouraging doesn't [actually] [14:55] prove for exercise doesn't tell you what exercise is doing or how it's doing it, but I think it provides you that step one. So, on the basis of that data, we're now upstairs in this building Zuckerman doing the preclinical studies just like you would with a drug, we want to understand if indeed it has effects against the cancer itself, where we can take all these other confounding factors out of the picture. And it turns out that, at least in our models of breast cancer, that yes, it does appear that exercise does slow cancer growth in a number of different models. And now we're getting into the biological studies to really find out why and it does appear that immune is a big part of that. So incredibly exciting times. Again, what is this specific mechanism? I think if you look at the role of exercise, there was a study published a couple of years ago, I think, in 1.4 million individuals and high levels of exercise, decrease the risk of 13 different types of cancer. So it's incredibly powerful. There's few drugs that I know that can have that broad impact over, but again, I think what we'll get to hopefully on the pod is, what specific is I think we've [clustered] [indiscernible] [16:05] and [thought] about exercise for everything and I think it's a little bit more specific than that.

[0:16:08] Dr. Diane:  So that's where we get into right now. Is there a secret sauce? So all exercises clearly not the same. We have aerobic we have anaerobic we have different intensities different cadence. So, is there a sort of exercise prescription, if you will, that we know in 2019, for an individual exercise patient that could be helpful in potentially helping with all these beneficial effects?

[0:16:31] Dr. Lee:  So my answer to that would be no. But in the same vein if I asked you, is there one type of chemotherapy dose that would be available for all patients? And you'd say no, you probably think that my answer would be yes. But I think this is why exercise research has been over the past 50 years. It's been very much a one size fits all approach. And Charlie said it from the get go is he came in at a different physiologic condition probably because of his years of being an athlete. And because of that he knew how his body responded. But even with that, he knew that he how to push himself and then take rest days when appropriate. So if I said, well, that's the exercise prescription for everybody with [colorectal] [17:11] cancer, that wouldn't be the case. So for me, just like we talk about personalized medicine, precision oncology, where we're really trying to dial in certain types of cancer therapies to the person and the molecular profile of the tumor, we think about it the same way from an exercise perspective, where we can take into consideration the physiology of a person, you know, where is that baseline exercise tolerance that the patient presents with? We then use that information to design individualized exercise prescriptions, knowing that everybody's going to respond a little bit differently, and where our tumor biology research is going now is also trying to understand not only physiology it’s tailored prescription for the biology of the tumor, to then tailor prescriptions. So for me, it's incredibly exciting and so unfortunate, I can't say there's a one size fits all because I simply don't believe in that and in a place like MSK, I don't think I should be saying that either. And so there are exercise guidelines of cancer survivors. But I just simply don't agree with that I think we got to treat everybody like an individual.

[0:18:07] Dr. Diane:  Absolutely and certainly there are some precautions in some patients that have underlying heart disease or lung problems and other things that, again, we don't want them to get out and run a marathon or think at all that that is something that could be helpful. So it completely makes sense that obviously none of us are a one size fits all type of approach in anything that we do.

[0:18:23] Dr. Lee:  Right, so we approach it in that manner, where we're trying to get a really good sense of how individuals are doing either before they start the treatment or during their dream or after their treatment to really understand what their baseline is, and then use that information to prescribe exercise that is tailored to them. And so that makes absolute sense. And so that's the way that we go after it.

[0:18:44] Dr. Diane:  So I'm a big believer but I'm an oncologist and so I have you thankfully and your trials to potentially enroll patients but what would you say to the oncologist as well as the patient in 2019 that do want to take some active role and control, cancer is one of the most devastating diseases because all of a sudden you lose the sense of control. And so there's a lot out there in terms of things that I kind of call hogwash. But I do think that exercise is one that really does sort of hit the boxes on potentially helping our patients provide that control. But as you said so beautifully, like, we're not there yet to know exactly for each individualized patient what's the right prescription?

[0:19:23] Dr. Lee:  It's a tough question, actually. And unfortunately, unlike things like heart disease and diabetes, cancer is not a qualifying diagnosis right now for exercise rehabilitation like it is for those other common conditions. So as much as I'd like to say, come to Memorial dial this number, you'll get referred to an exercise physiologist who can give you a personalized prescription, that does not exist at Memorial Sloan Kettering, it doesn't really exist anywhere in the country. One of my jobs, of course as a researcher is create the evidence base to try and convince third party payers insurance companies that that should be the case. And I think it is a question of when not if that data is coming and I think this is quickly going to be the case, but in 2019, what is the answer to that? Well, if you’re in Memorial Sloan Kettering-

[0:20:05] Dr. Diane:  Get on a trial.

[0:20:06] Dr. Lee:  Well, get on trial, give me a phone call, drop me an email, because it will all mean and there is our team that can, we can certainly help you as much as we can. Outside of that is trying to I would try and sort out, talk to your oncologists about local resources, talk about local rehabilitation, going to exercise professionals that are out there, and really getting that professional advice to begin with, because I think it is difficult to try and start on your own because you don't necessarily know how often should I be doing, how much should I push myself? How far should I go? And that can become very demotivational I would have thought, so there are the resources out there, they might be hidden. But I think going and pushing your oncologist a little bit to try and find some of this information, I think is the way to go.

[0:20:46] Dr. Diane:  Any last minute words for the patient themselves.

[0:20:48]  Dr. Lee:  I mean, I think you're actually right. I think other than all the physiology and the biology that we talk about. I think the sense of control is massive and exercise is something that you can do. That's 100% under your control to influence your own trajectory of recovery. So those individuals are not doing anything right now, even just going out a few days a week for even 10 to 15 minutes a light walk. That's how you get going. I think once you get that you can start building from there really. And I think even just doing that it's associated with [inaudible]  [0:21:17]. Again, we know how doing nothing is so bad for you. So just taking every opportunity to try and be active is a step in the right direction.

[0:21:26] Dr. Diane:  Absolutely. And it sounds like, again, at least early data suggests that patients that are about to go for surgery after surgery about to get chemo, whether it's for curative intent or control the disease for as long as possible. There seems to be a role for that type of movement.

[0:21:41] Dr. Lee:  Yeah, I would say this data is supported across the entire continuum, whether its individuals who are newly diagnosed, like I said, those who are starting treatment after their surgery, individuals who completed their treatment, but also we just completed a study last year and individuals who were diagnosed with metastatic breast cancer when we found benefits. So, I think within that, that is not course for everybody. But I think within that across the entire continuum, there's data to support that exercise can be beneficial.

[0:22:06] Dr. Diane:  Charlie, anything that you'd like to close on.

[0:22:08] Charlie:  I would just echo what I think both of you have said in the element of control to the extent that as a patient, you can identify something that you attach to that gives you a sense of control and something that enables you or at least mentally to feel like you're battling back and you're striking back at the disease is incredibly important. So whether that's exercise, diet, meditation, a combination of all or a number of different things, which is what I have kind of administered myself, it's really important for the mental piece of the battle, which is hugely important. And it's something that I'm a huge believer.

[0:22:39] Dr. Diane:  Absolutely, I think it's hard because you go out to the Internet, and there's a lot of stuff out there. And sometimes there's a lot of conviction of things that may not only not work, but actually could do harm. So these types of interventions, although the data have yet to definitively prove exactly what they do. I think there's enough out there that suggest that this one's a good one. So we give it a thumbs up most of our patients if they're out there to consider some type of moving and getting up. I want to thank Dr. Lee Jones exercise scientist and Charlie Sweeney, Mr. Super fitness for inspiring us. To all of those listening nothing great has ever accomplished without sweat and hard work. Keep on going and get to that gym. Because you can. You're stronger than you think. Thank you for listening to Cancer Straight Talk from Memorial Sloan Kettering Cancer Center. For more information or to send us any questions you may have, please visit mskcc.org/podcast. Help other people find this helpful resource by rating and reviewing this podcast at Apple podcasts or wherever you listen to your podcasts. These episodes are for you, but are not intended to be a medical substitute. Please remember to consult your doctor with any questions you have regarding medical conditions. I'm Dr. Diane Reidy-Lagunes onward and upward.

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