Keeping Fit and Staying Active

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1 Keeping Fit and Staying Active physical activity matters Kirsten A. Nyrop, PhD Division of Hematology/Oncology Cancer and Older Adults: Care and Treatment November 14, 2014, UNC Friday Center

2 THEME: Physical Activity Is something you can do for yourself 11/20/14 2

3 GUIDELINES Centers for Disease Control and Prevention (CDC)! for adults age 65 or older 30 minutes or more of moderate physical activity, 5 or more days a week = at least 150 minutes of physical activity a week American Cancer Society! For adults with a cancer diagnosis the same amount!!! Both during treatment and after treatment!!! (Guidelines for Nutrition and Physical Activity for Cancer Prevention; Kushi /20/14 3

4 Benefits of Physical Activity for Adults with a Cancer Diagnosis Less fatigue, more energy. Less depression, anxiety. Fewer sleep problems. Improved body image. Overall improved health. Overall improved quality of life. 11/20/14 4

5 Epidemiologic Studies Prognosis and Survival Meta-analysis of 6 studies of women with a breast cancer diagnosis à post-diagnosis physical activity (Ibrahim 2011)» Reduced breast cancer deaths by 34%» Reduced all cause mortality by 41%» Reduced breast cancer recurrence by 24% Meta-analysis of 16 studies of post-diagnosis physical activity among breast cancer survivors (Zhong 2014)» Moderate (as compared to low-level physical activity) reduced all-cause mortality by 39%» High (as compared to low-level physical activity) reduced all-cause mortality by 48% 11/20/14 5

6 What is Moderate-Intensity Activity Exercise and leisure: walking, dancing, leisurely bicycling, ice and roller skating, canoeing, yoga, horseback riding Home activities: mowing the lawn, general yard and garden maintenance 11/20/14 6

7 S.M.A.R.T. START low and go slow» 3-5 minutes day/twice a day MODIFY your physical activity if joint symptoms increase but try to stay active» No need to aim for a marathon ACTIVITIES should be joint friendly» Walking, bicycling, water aerobics, dancing RECOGNIZE safe places and ways to be active» Sidewalks or pathways that are level and well-lit» Start and maintain an activity plan TALK to a health professional or a certified exercise specialist» Talk with your oncologist about your plans to be more physically active» Talk with your general practitioner 11/20/14 7

8 Research at UNC 11/20/14 8

9 UNC Research There have been well over 200 randomized controlled trials (gold standard) of physical activity interventions both during cancer treatment and in survivorship. However, there are some important gaps in the literature Inadequate focus on persons age 65 and older Need for real world interventions that are scalable within busy oncology clinics (low cost, easy to explain to the patient, easy for the patient to do at home) Specific issues à potential for physical activity to treatmentrelated toxicities and side effects» Joint pain, stiffness, achiness» Biomarkers» Fatigue 11/20/14 9

UNC Research -- Pain WALKING to reduce joint pain, stiffness or achiness (arthralgia) in breast cancer survivors on adjuvant aromatase inhibitor Post-menopausal, hormone receptor positive tumor à

10 UNC Research -- Pain WALKING to reduce joint pain, stiffness or achiness (arthralgia) in breast cancer survivors on adjuvant aromatase inhibitor Post-menopausal, hormone receptor positive tumor à Exemestane (Aromasin ), Anastrozole (Arimidex ), Letrozole (Femara ) 2012 study of survivors age 65 or older (N=30) Pilot test! 6 weeks FINDINGS» Safe à no falls or other adverse events» Feasible à met recruitment and retention goals» Promising results (Nyrop 2014) Average minutes walked increased 58% Joint stiffness decreased 32% Fatigue decreased 19% 11/20/14 10

11 UNC Research -- Pain Interviews Since I started walking, I found out I could do more than I thought I could. I wouldn t quit for anything because it s doing so much good. After your breast cancer diagnosis, you realize you need to take care of yourself. This is a way of taking care of yourself. I feel more energetic for the rest of the day. I have a sense of my own well-being and feel more clear-headed. I absolutely felt the connection between AI symptoms and exercise. On days I don t walk, I am stiff. But if I walk, I am not stiff. Keep moving, it really helps. I was really surprised. My blood pressure is down, and it has stayed down consistently. I lost a little weight. Walking seems to help me sleep, too. I have suggested to many people that walking is good. 11/20/14 11

12 UNC Research -- Pain Federal Grant (R21, Callahan) July 2013-July year study of breast cancer survivors age 21 and older (mean age 66) on AI therapy who are experiencing moderate to severe arthralgia (N=80) As we recruit participants for this study, we are learning about in-clinic patterns of physical activity and moderate to severe joint symptoms» Opportunity to contribute to the literature On-going randomized controlled trial à Intervention compared to Wait List Control, and 6 months follow-up More interviews 11/20/14 12

13 INTERVIEW findings (1) Study participants had little recollection of having a discussion of potential joint pain side effects when they were prescribed an AI.» They were surprised ( blind-sided ) when they experienced new joint pain/symptoms very severe pain. or Take away: Oncologists should inquire about joint symptoms pain during routine clinic visits à it can take 6 weeks to 2 years for symptoms to occur. Take away: Women on AI therapy should raise the issue à ask if their joint symptoms might be an AI side-effect (not arthritis or aging ). 11/20/14 13

INTERVIEW findings (2) Patients want to know as early as possible that physical activity walking could prevent or ease their joint symptoms à don t wait until symptoms occur;

14 INTERVIEW findings (2) Patients want to know as early as possible that physical activity walking could prevent or ease their joint symptoms à don t wait until symptoms occur; be pro-active. Take away: The oncologist is the most important (influential) person to recommend physical activity. She saved my life I will do whatever she says. 11/20/14 14

15 UNC Research -- Biomarkers Dr. Muss has received grants to conduct two walking studies of breast cancer patients during chemotherapy Age 65 or older (Kay Yow Jimmy V Foundation) Age 21 to 64 (Breast Cancer Research Foundation) Biomarker of aging! p16ink4a» Ned Sharpless, MD lab at UNC p16 increases during chemotherapy (Sanoff 2014) p16 is lower among people who are physically active In mice, physical activity lowers p16» On-going studies to see if walking during chemotherapy can moderate the increase in p16 11/20/14 15

16 UNC Research -- Fatigue Lineberger Comprehensive Cancer Center funding à cancer survivors age 65 or older wide variety of cancer types (not just breast cancer) within 5 months of completing chemotherapy Objective à can walking reduce post-treatment fatigue Recruiting through UNC Cancer Networkà Rex Hospital, Rex Wakefield, Pardee Memorial Hospital (Hendersonville), Mission Health (Asheville), Cone Health (Greensboro), Seby B Jones Cancer Center (Boone), and Nash Healthcare System (Rocky Mount) ALSO -- Grant Williams, MD -- Hartford Foundation funding for a walking intervention in colorectal cancer patients age 65+ during chemotherapy à focus bon fatigue and physical function 11/20/14 16

17 Back to The Challenge 11/20/14 17

150 minutes a week during treatment» Improve prognosis and survival» Reduce treatment-related toxicities» Maintain and

18 The Challenge All adults should exercise at least moderately 150 at least 150 minutes a week» Lower their cancer risk» [Also lower risk for heart disease, diabetes, arthritis, obesity] Get adults with a cancer diagnosis à aim to exercise 150 minutes a week during treatment» Improve prognosis and survival» Reduce treatment-related toxicities» Maintain and rebuild physical function» Maintain and rebuild quality of life And keep exercising throughout survivorship! 11/20/14 18

19 If it s so easy why isn t everybody doing it? Caregiver for spouse, other family responsibilities The weather too hot, too cold, too rainy Too busy can t find the time in a busy day On vacation House guests Procrastination I ll get started in the New Year 11/20/14 19

20 Find your Motivation 11/20/14 20

21 Lots of ways to walk 11/20/14 21

22 How to Get Motivated How you reach the goal of 30 minutes a day of walking for exercise or pleasure is up to you» Where, when, with whom you walk» Time, distance, pace Try starting with minutes a day and then increase the amount of time gradually» Walk in increments some in the morning, some in the afternoon Any amount of walking is good as long as it is safe, comfortable, regular, and as often as possible Even modest increases in physical activity among older adults can make a substantial contribution to disability-free life expectancy!!! (Feinglass 2005) 11/20/14 22

23 Something to think about Every pound of body weight yields five pounds of force on the knee. Just 10 pounds of extra weight can put a considerable load on those joints the equivalent of 50 pounds (= two large bags of dog food) (Messier 2013) 11/20/14 23

24 My Walking Plan! My walking goal» days a week» total minutes a day My reasons for walking Best days and times for me to walk Possible walking buddies What I will tell myself to stay motivated on days when walking is hard My walking start date! 11/20/14 24

25 Walking is just the beginning 11/20/14 25

26 THANKS!!! Hy Muss, MD fearless leader and early convert to walking works Shani Alston research coordinator extraordinaire Betsy Hackney, Nora Christopher and Ken Norman study recruiters who will not be denied UNC Cancer Hospital breast cancer oncology MDs, NPs and Nurse Navigators spreading the gospel of walking works Cancer patients and survivors participating our studies keep on walking!!!! 11/20/14 26

27 Thank you! 11/20/14 27

Changing Practice: Provider-Patient Conversations about Physical Activity

Changing Practice: Provider-Patient Conversations about Physical Activity An Opportunity for Research Collaboration April 14, 2016 Kirsten A. Nyrop, PhD Research Assistant Professor Div. of Hematology-Oncology