Vida! Educational Series - Health Care Professionals Welcome! - We will begin shortly

1. Vida! Educational Series - Health Care ProfessionalsWelcome! - We will begin shortly If viewing by internet: for technical help: 520-626-0167 Please complete surveys:http://streaming.biocom.arizona.edu/ To call in with your questions/comments (best to call in early) 520-626-2801

2. Exerciseafter Breast Cancer: Promoting a Healthy, Happy Recovery Joy Kiviat, PhD, MSN, RN Oncology Certified Nurse University of Arizona College of Nursing ACSM certified Cancer Exercise Trainer and Group Exercise Instructor

3. Educational Objectives • Participants will: • describe specific health benefits of exercise for the breast cancer survivor • evaluate research findings on safety and efficacy of exercise • recognize need for providers to discuss exercise with cancer patients • state appropriate goals for aerobic and resistance exercise duration and intensity • identify local and regional exercise resources

4. Cancer & Exercise Research indicates that cancer patients who exercise: • report less fatigue • require fewer blood transfusions • are hospitalized less frequently • are less likely to fall • have better outcomes and improved sense of well-being

5. Consensus: Exercise is Beneficial, During and After Cancer Treatment 2012:American Cancer Society guidelines for nutrition and physical activity strongly support exercise as an important part of survivorship care planning (Rock et al., 2012).

6. Exercise promotes Recovery, AND…. • Reduces overall mortality among survivors • Evidence is mounting that moderate activity and a healthy weight canhelp prevent cancer recurrence • Strongest evidence in breast and colon cancer; recent studies suggest exercise reduces risk for prostate and brain cancer recurrence too. (Loprinzi et al., 2012; Pekmezi & Demark-Wahnefried, 2011)

7. How does exercise help? Increased lean body mass, decreased fat Improved cardiovascular condition (lowers risk of embolism, heart attack and stroke) Increased bone density and improved balance (reduces risk of falls and injury) Immune system stimulation (reduces risk for infection and recurrence) Release of endorphins and other stimulatory neurotransmitters (elevates mood)

8. Improving Balance

9. Body Fat& Cancer-What’s the link? Higher energy (calorie) intake leads to: ↑ Insulin & insulin-related growth factors ↑ Free Estrogen & Androgens ↑ Leptin, ↓adiponectin =>↑ tumor growth ↑ Inflammatory chemical messengers Result: more fuel available for cancer cell growth, excess hormones, and weaker immune response to abnormal cells Source: Annual Report to the Nation on the status of cancer, 1975-2008, featuring cancers associated with excess weight and lack of sufficient physical activity. (CDC, 2012)

10. How do we know? 2009 Study: Patients treated for breast cancer enrolled in 12 weeks aerobic and strength training exercise – compared to “usual care” they had significant gains in fitness, strength, lean body mass, and overall quality of life. (Rogers et al., 2009) 2011 Review of 21 RCTs showed exercise is safe for cancer survivors, and improves physical fitness and psychosocial well-being (Pekmezi & Demark-Wahnefried, 2011). 2012 Systematic review: 27 high quality studies of activity and cancer outcomes showed consistent evidence of reduced cancer-related mortality and improved biomarker and immunity profiles.((Ballard-Barbash et al., 2012)

11. Overcoming Barriers • Provider education: most oncologists aware of exercise benefits, but primary care providers may not be informed*. • Exercise prescription pads for oncologists • Include exercise in Survivor Care Plan • Patient education: convince survivors of immediate and long-term benefits • Community presentations, brochures *Sabatino et al. (2007)

12. Increased Flexibility

13. Common Concerns of Survivors • Fatigue: Just want to rest… • Safety: Am I ready to exercise? • Could I get injured, will this interfere with recovery, risk for infection…many concerns • Cost: fitness center membership, personal trainers, may be out of reach for some • Access: location, transportation, time of day…..What do YOU recommend?

14. Addressing Concerns Readiness test Motivating Preparing Persisting Evaluating

15. Exercise Readiness Test* Answer yes or no to the following questions: • Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor? • Do you feel pain in your chest when you do physical activity? • In the past month, have you had chest pain when you were not doing physical activity? • Do you lose your balance because of dizziness or do you ever lose consciousness? • Do you have a bone or joint problem that could be made worse by a change in your physical activity? • Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition? • Do you know of any other reason why you should not do physical activity? • *Adapted from Physical Activity Readiness Questionnaire (PAR-Q) developed by the British Columbia Ministry of Health & Multidisciplinary • Board on Exercise

16. Readiness Results If you answered yes to any question: • consult a physician before increasing physical activity • ask for a medical clearance and any exercise limitations • in most cases, you will still be able to do any type of activity you want as long as you adhere to some guidelines If you answered no to all: • you can be confident that you can exercise safely • It is still important to start slow, increase gradually

17. What about Lymphedema? Recent study showed upper body resistance exercise does not increase swelling and was associated with 50% decrease in exacerbations (Schmitz et al., 2009) 141 women with stable lymphedema and no previous hx of weightlifting, randomized to 2x/wk weight training or control group for 1 year NLN 2011 guidelines: Start with low resistance, incremental increase with regular measurements; advise compression garment if lymphedema already present No controlled studies on value of compression garments during exercise for prevention of lymphedema

18. Exercise Options Group classes (YMCA, community centers, fitness clubs) Personal trainer (some make house calls) Walking (suggest finding walking buddy or dog for companionship and motivation Swimming (good for persons with joint or bone pain) Exercise videos and FitTV channel Better than Ever program at UACancer Center

19. How Much is Enough? ACS & ACSM roundtable concluded cancer survivors should strive for: • 150 minutes/week aerobic exercise (aim for 30 minutes, 5 days a week; try brisk walk, run, swim, dance) • 2-3 sessions/week resistance exercise (weights, bands, water bottles… 1-2 days off between sessions) • Daily stretching/toning Source: Schmitz et al., 2010

20. References Ballard-Barbash, R., Friedenreich, C., Courneya, K., Sameer, M., Siddiqi, S., McTiernan, A. & Alfano, C. (2012). Physical activity, biomarkers, and disease outcomes in cancer survivors: A systematic review. Journal of the National Cancer Institute 104(11): 815-840doi:10.1093/jnci/djs207 Irwin, M. (2008). Physical activity interventions for cancer survivors. British Journal of Sports Medicine 32(8) 32-38. doi:10.1136/ bjsm.2008.053843 Loprinzi, P., Cardinal,B., Winters-stone, K., Smit,E. & Loprinzi, C. (2012) Physical activity and the risk of breast cancer recurrence: A literature review. Oncology Nursing Forum 39(9) 269-74. doi:10.1188/12/12.ONF.269-274 Pekmezi, D. W., & Demark-Wahnefried, W. (2011). Updated evidence in support of diet and exercise interventions in cancer survivors. Acta Oncol, 50(2), 167-178. doi: 10.3109/0284186X.2010.529822 Rausch, S., Millay, S., Scott, C.,Pruthi, S., Clark, M., Patten, C., ….Vachon, C. (2012). Health behaviors among cancer survivors receiving screening mammography. American Journal of Clinical Oncology. 35(1), 22-31.

21. References, cont. Rock,C.L., Doyle,C., Demark-Wahnefried,W., Meyerhardt, J., Courneya,K. S., Schwartz, A. L., Bandera, E. V., …, & Gansler,T. (2012), Nutrition and physical activity guidelines for cancer survivors. CA: A Cancer Journal for Clinicians. doi: 10.3322/caac.21142 Rogers, L., Hopkins-Price ,P., Vicari,S., Pamenter,R., Courneya,K., Markwell ,S., … Lowy, M. (2009). A randomized trial to increase physical activity in breast cancer survivors. Medical Science Sports Exercise 41(4), 935-46. Sabatino, S., Coates, R., Uhler R., Pollack, L., Alley, L., & Zauderer, L. (2007). Provider counseling about health behaviors among cancer survivors in the United States. Journal of Clinical Oncology 25(15) 2100-2106. Schmitz, K., Courneya, K., Matthews, C, Demark-Wahnefried, W, Galvao, D.,…, & Schwartz, A. (2010). American College of Sports Medicine Roundtable on Exercise Guidelines for Cancer Survivors. Medicine & Science in Sports & Exercise 42, 1409–1426. Schmitz,K., Ahmed,R., Troxel,A.,Cheville,A., Smith,R., Lewis-Grant,L., Bryan,C., Williams-Smith,C., & Greene,Q. (2009). Weight lifting in women with breast-cancer–related lymphedema. New England Journal of Medicine 361:664-73.