The Oncology Podcast

Movement Medicine: Exercise Interventions in Cancer Care

• Professor Bogda Koczwara AM • Season 1 • Episode 12

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Welcome to the latest episode of Supportive Care Matters. Join Medical Oncologist Professor Bogda Koczwara AM and Dr. David Mizrahi,  Exercise Physiologist and Research Fellow at the Daffodil Center, University of Sydney. 

Learn how precisely prescribed exercise can transform not just the physical health but also the clinical outcomes for cancer patients. We break down the distinctions between exercise and physical activity, showing how each contributes uniquely to improved mood, heart health, muscle strength and metabolic health. 

Dr. Mizrahi shares ground-breaking insights on how integrating exercise into cancer treatment regimes can not only enhance survival rates and reduce chronic disease risks but also alleviate the financial burdens on healthcare systems.

Discover innovative methods to incorporate physical activity into cancer treatments, such as the use of mini bikes during chemotherapy at Chris O'Brien Lifehouse. We discuss exciting, play-based exercise initiatives for children undergoing cancer treatment and the importance of healthcare providers setting a proactive example. 

By the end of this episode, you'll come away inspired by practical strategies and real-world examples, reaffirming that every bit of movement counts on the journey to better health for cancer patients. 

Visit www.oncologynews.com.au for show notes and more information about Supportive Care Matters!

This conversation is proudly produced by The Oncology Network.

Bogda Koczwara:

Have you had your exercise today? No, well, if you need some motivation, this next guest is just the man. I'm Bogda Kozwarra and this is Supportive Care Matters. My guest today is Dr David Mizrahi. David is a research fellow at the Daffodil Center at the University of Sydney, researching exercise during and after cancer treatment in adults and children. He is the chair of the Exercise and Cancer Committee for Clinical Oncology Society of Australia and he recently was awarded as Accredited Exercise Physiologist of the Year. Welcome to the podcast, david.

David Mizrahi:

Thank you so much, Bogda, for having me along. It's a pleasure to be here.

Bogda Koczwara:

So we're going to talk exercise or maybe physical activity, or both. So I think we should really start with some definitions what's exercise, what's physical activity?

David Mizrahi:

Yeah, it's a really important delineation of the term. So exercise is more structured repeated bouts of physical activity. So exercise is more structured repeated bouts of physical activity. Particularly in a clinical setting it can be more of a prescription where we have specific targets based on dose or intensity of the physical movements, whereas physical activity can refer to any type of bodily movement that can be tiring to the muscles. So that can be things like gardening or walking or more leisure type activities as well, like bushwalking and hiking. They're all fantastic, any movement is great. But in terms of clinical exercise interventions that are done with clinical populations such as people with cancer or heart disease or other populations, a lot of the research has done exercise trials where they might give a particular dose of cardio or aerobic exercise, for example at a targeted heart rate, or resistance exercise at a targeted muscle strength ability as well. So there's the two differences. In general, the term physical activity is more inclusive and it can be less intimidating term to use as well for people, particularly when they're starting off.

Bogda Koczwara:

So they both are good for you, and perhaps exercise is a little bit easier to prescribe because it's more specific. But why are they good for you? What are the benefits, in particular for people with a history of cancer diagnosis?

David Mizrahi:

Oh, there's so many benefits from exercise. We know that exercise and physical activity there's many, many physical and emotional benefits in general, for the general population.

David Mizrahi:

We know we feel better when we do it, so there's neurobiological pathways that you get some benefits in your mood from very shortly after doing exercise. We know that our heart can become strengthened when we do cardio exercise. Exercise has been given to people with heart disease for decades now. We know that people can improve their strength. So when you do resistance exercise it causes tiny micro damage to the muscles that actually heals and becomes stronger. So we get stronger muscles and that's great, particularly for older patients or people with balance problems or people who have deconditioning, for example, through cancer treatment. They can get stronger muscles so they can preserve and maintain their functional capacity to keep doing the tasks that they want to do, whether it be their ability to work or pick up their grandkids or just be able to even get back to the activities like golf or anything that they want to be able to do. Also, there's other benefits as well, like metabolic health.

David Mizrahi:

We know that people with diabetes again, have been prescribed exercise for a long, long time and there's many benefits there. It can improve lung function as well, which is particularly important. And I can really go on as well for the different types of benefits. But all those different benefits that you get from exercise then can improve your clinical outcomes. So people are more likely to live longer and less likely to actually develop chronic diseases as a result of having that healthy lifestyle. So you can start to see that there's many benefits there. And there's this famous quote. I suppose that if all the benefits from exercise could be wrapped up into a little pill, every single doctor would be prescribing it. Unfortunately, it just takes a little bit of hard work compared to taking a pill.

Bogda Koczwara:

Yes, it's a little bit harder than putting it in the water supply, isn't it?

David Mizrahi:

That's right. That could be a good way to do it, and putting it in the water supply isn't it.

Bogda Koczwara:

That's right. That could be a good way to do it Now. You've listed exercise benefits on individuals, both in terms of physical strength, greater well-being, potentially even improved survival, less chronic diseases. You've also published on the benefits of exercise in terms of how it benefits the health system, because it might reduce hospital stay. Tell us about these research findings.

David Mizrahi:

Yeah, this is something that we've been looking into a bit more recently. So we've been seeing for decades now that patients will benefit physically and emotionally from doing exercise. We know that already, so now we're looking more deeper. How can patients who are more active, how can that help improve the health system? So I published a meta-analysis recently in the British Journal of Sports Medicine that synthesized all the studies that looked at hospital stays for patients who were doing exercise during their primary cancer treatment, and what those studies found was that when patients were doing exercise programs during their chemo or their radiation or their stem cell transplant, they were less likely to be admitted to hospital. They had shorter hospital stays as well. What that's telling us is that exercise actually has benefits in terms of reducing hospital stay. That can save thousands and thousands of dollars per patient per stay and particularly over the thousands of patients that are diagnosed each year. That can be enormous savings for a very cheap intervention that exercise can be.

David Mizrahi:

Now there's numerous potential mechanisms for these benefits.

David Mizrahi:

For example, there can be unexpected hospital admissions for patients who have falls and become very fragile and have a lot of deconditioning.

David Mizrahi:

So patients who improve their strength and the functional capacity are less likely to have a fall.

David Mizrahi:

This can also occur for patients who develop peripheral neuropathy, which is really common from some neurotoxic chemotherapy agents. So if patients can preserve their balance when they can't feel their feet very well because of their neuropathy, that can as well potentially lead to them preventing them from having a fall and an unexpected admission. Also, patients who are more active can be able to tolerate their treatment better because they're fitter, they're stronger, they're less likely to have adverse events resulting from their treatment, and that's something that's been quite established in the previous literature that patients who are fitter where they test them with exercise tests are getting less adverse events. So if we can get patients active or at least promote the use and endorsement of exercise right from the beginning of treatment, we can fight these side effects that we know are so common from treatment. We can fight them early on and hopefully prevent the need for patients to have unexpected stays in hospital, which can be quite worrying to patients and their families, particularly if it was not expected, not in their plan.

Bogda Koczwara:

And of course it's a strain on the healthcare dollar as well.

David Mizrahi:

Yeah, certainly. I mean the cost depends on each centre, but it can be thousands of dollars each day from being admitted to hospital. So if a patient has an unexpected stay for four or five days, that's really a lot of money that adds up so quickly. So we want to keep patients out of hospital if they don't need to be there and that money again can be better spent on other things. So exercise physiologists and physiotherapists or allied health professionals they're not expensive to hire. In that context, if we can save all that money and rather invest that into those health professionals to service the patients that can get benefit from doing exercise, that would be fantastic, because currently most hospitals in Australia don't have access to those programs. So it's really quite a gap in the system right now.

Bogda Koczwara:

That's right. So health economic argument might actually win that and perhaps change how we deliver care.

David Mizrahi:

That's right. I guess we'll have to watch this space, but we do have investigations underway in that topic. We've got COSA, the First Exercise and Cancer Fellowship, which is currently underway, which is Dr Kim Edmonds. He is looking at the health economic evaluation of exercise and cancer trials to answer that question. So we'll have more information later in the year, presented hopefully at the COSA ASM.

Bogda Koczwara:

Fantastic. Well, watch this space with a lot of interest. So, now that we know that exercise is great for you, how do we start? What type of exercise, how long for? And is the prescription for exercise for people with history of cancer the same as for somebody who doesn't have a cancer diagnosis?

David Mizrahi:

A million dollar question. You're asking all the hard questions here, pankaj. So I mean, where do we start? It really depends on the center. I think it's super important if the clinician in charge of the patient is sending the message that exercise is both safe and beneficial, because patients will listen to their doctors. If they're not pushing that message, they're not portraying that at the important moments of diagnosis and other times in their consults, patients might not take it as seriously and it will put it into the box that it's something that would be nice but not essential. If we can get all patients active, we know that they'll cope with treatment better. So it is something that needs to be discussed from the beginning. So that's one thing that's quite important. Other things I'm discussing well, I guess it's making those partnerships with community health services. If you don't have in-house exercise professionals, so you have the ability to refer patients to an exercise professional that you know and trust and particularly one that you can potentially communicate with, because if your patient's undergoing treatment and you're referring them out to the community setting, they may have questions to ensure the safety of your patient. So having that two-way communication channel between tertiary hospital and community exercise professionals is best, I suppose, for patient care.

David Mizrahi:

Now, in terms of what exercise to do, it's extremely individualized. Anything is better than nothing. The health recommendations or the guidelines do recommend up to around 150 minutes of moderate to vigorous cardio type exercise. So walking, jogging or hills, swimming, cycling. So 30 minutes on most days of the week, but also two sessions of resistance type exercise. So that can be doing weights or resistance bands or even using your body weight, for example, doing squats out of a chair or pushups against the wall.

David Mizrahi:

But to be honest, if someone likes doing something like if someone only likes yoga and doesn't want to do anything else, even though it's not optimum, they're not doing everything, I don't mind, because they're compliant. If they really love something and they're doing it lots, then that's fantastic. We don't want to fall into the trap of people just sticking with low intensity exercise like they're only going for walks, for example. I think it's important to reiterate that it's great and it's better than nothing. But we do need to get challenging type exercise in to really get the benefits, because exercise is a dose response, beneficial intervention, that the more you do and the harder you do it, the more benefits you start to get.

David Mizrahi:

But yeah, I think for some people who haven't done exercise before, that's where it can be a good challenge to teach people what's beneficial for them, particularly if if they haven't done, for example, resistance exercise before. So we'll be starting really, really easy in their programs, just to get them comfortable and not an intimidating environment, and then slowly building up and usually after about a month people really love it, they start to get really into it something they've never done before and they can feel the benefits. So that's really rewarding once you get to that stage. But yeah, starting it off is certainly the hard part.

Bogda Koczwara:

I'm reflecting on the fact that our thinking about exercise have changed quite dramatically over the past few years. I remember the patients who I treated who would come into my clinic and say my doctor told me that during chemotherapy I should do nothing and rest and I can really pick things up after I finish my chemotherapy, which is, in my line of work, quite problematic because some of the chemotherapy that I give takes a year and sitting on the couch for a year is probably not good for your health. You were quite innovative in putting exercise equipment into the chemotherapy room. How did that work out for you?

David Mizrahi:

Yeah, honestly it comes down to the support of the organization. And where I was at we did exercise for women with three lapsed ovarian cancer and it's quite a deconditioned group, poor prognosis, but they loved doing the exercise it was. You know it was a culture shift. Like you said, there was a time where people were told just to rest, do nothing, but only after a couple of weeks you really start to decondition, you lose muscle mass, you lose cardiovascular fitness and that can increase your risk for cardiovascular disease. So it's a shift. Honestly it's a strange shift, but all the nurses are on board. That exercise can be beneficial. We've got bikes.

David Mizrahi:

Now in a study that's happening in Chris O'Brien Lifehouse, patients who are actually having chemotherapy infusion at the same time and you know they come in for hours at a time, sometimes patients even bored, sometimes they want to do something sitting just pedaling away on the. We sometimes patients even bored, sometimes they want to do something sitting just pedaling away on the. We have this mini bikes we bring in and they love it. We don't do very high intensity, it's probably low to moderate intensity. They're not really getting sweaty or anything, but they feel good when doing it. So we're monitoring their heart rate. We do questionnaires as well, looking at their fatigue during and after and also acceptability of an intervention like this. And I remember hearing about this from lee jones, a researcher from new york, and, I think, lots of their clinics in the states. They all have bikes accessible to them and that's what we're going to do in one of my projects.

David Mizrahi:

Soon I'm going to be doing a study for children who are recently diagnosed with cancer. They're often in patients a lot and, particularly if they're having a transplant, maybe they're for weeks and weeks and weeks, and it's boring. We want to be able to get them to do something that can be fun, games-based, play-based Nintendo Wii's moving around throwing a ball to each other, stationary bike for the older kids. Yeah, it's about a culture shift. I think is important. We already have it in cardiac rehab. It's been the norm. If you have a heart attack or a stroke, you get exercise. That's how it's been for decades now. So we need to copy their model and make it even better and ensure the health of our patients.

Bogda Koczwara:

But you correctly point out that this is not just providing the evidence. It's also shifting the culture within the environment within which we work, and I guess if we were to convince the patients that exercise is good for them, then we really need to demonstrate that ourselves. It's no good talking to the patient about exercise when you don't exercise and you sit in your consulting room eating something that's terribly unhealthy or not eating at all, for that matter. So I think we also need to influence the healthcare providers.

David Mizrahi:

How do you think we can do that? That's a hard one, isn't it, Bob? I know you're a keen runner and I'm a keen runner, but not everyone likes running. I know there's some keen medical professionals in the cancer space that do love exercise, but it's not for everyone. I just remember, like seeing a meme, I think, with like a doctor smoking back in the olden days.

David Mizrahi:

But yeah, obviously setting good examples is important. Like I know again at Lifehouse, there's a gym there for patients to use and sometimes one of the doctors comes down and goes for a run and the patients are so inspired by that. It really motivates them. It's a really nice thing. But I think that's going above and beyond, so it's obviously super inclusive. There's also I don't know where it was, but I think it's a GP initiative. It's obviously super inclusive. There's also I don't know where it was, but I think it's a GP initiative it's like a program that's called Walking With your Doctor or something like that. The doctor goes to a park and then the patients can go with them. It's like some public health initiative. It's actually a really nice, neat idea.

Bogda Koczwara:

It's better than walking with your dog. You could just walk with your doctor.

David Mizrahi:

You could bring your dog and visit your doctor. But I suppose, like leaning towards those type of things, it's a nice thing Like there's so many nice green spaces around plenty of some hospitals and you know, if we can be innovative and do programs like that, that's a really nice way to offer a nice physical intervention. But there's also social benefits as well from doing something like that.

Bogda Koczwara:

Yes, absolutely. Benefits as well from doing something like that. Yes, absolutely. And in Australia the climate is so accommodating that there are plenty of days when you can go for a walk or run or whatever without really worrying that you're going to be snowed under, so I think we should take advantage of it.

David Mizrahi:

Yeah, we are lucky. We have fantastic weather here. My sister was living in the US a couple of years ago and it snowed for like two, three months or something. It was minus 20 degrees. We don't really have to worry about that. It's a relatively safe country in most areas. Yes, it's quite lucky because some places around the world don't have that as much. So we do have lots of green spaces and we don't have to worry as much. So we are blessed and there's some beautiful beaches and some great places to do exercise. I mean in sydney, if you go anywhere along the coastline in the mornings you'll see lots of boot camp groups and people out and about.

David Mizrahi:

But I think that's important in the cancer setting to, I guess, portray that exercise and physical activity. And this is something a conversation I have with patients. It's quite a blunt conversation. I might say that what they might be able to do now is nothing like they were able to do before diagnosis. For the moment, it's going to be really hard and challenging at the beginning, and that's okay, because I think people might be intimidated that we're expecting them to do one of those boot camp classes that you see down at the beach and that's not what we're going to do. We're going to do something really basic, particularly if they have lost a lot of strength and fitness. So it's sending that positive message that something at the beginning is okay.

David Mizrahi:

There's a little quote that I also have used before Something is better than nothing, and more is better than less. So getting patients on board is really important. Before. Having a goal of getting back to the bootcamp class in Bondi Beach is definitely something that we can have, because that's what we do in our consults as exercise physiologists. We do a lot of behavior change and goal setting. That's really important for people to think why am I doing all this hard work and where do I want to get back to?

Bogda Koczwara:

When you talk to patients about physical activity, one of the things that sort of, when I talk to them, one of the things that often comes out is how it makes them cope better. And I think in many ways, when I think about difficult day in clinic when my patients are not well or where the clinic is overbooked or something goes wrong Physical activity is a way of coping emotionally and I think that there are in many ways. There are some similarities here where patients and healthcare providers can sort of learn from each other about using exercise as a way of sort of managing your life a little bit better. So it's not exactly either or yeah, no, it's definitely.

David Mizrahi:

I mean, I know that if I don't do exercise for just two or three days I get cabin fever and it really affects me. And if I have a long day of meetings and I can't even get out in a day, it really affects me. So just even having that 10 minute walk, like I think like there should be a culture shift as well to be doing walking meetings rather than just sitting all the time. If you're in an office-based job we're just sitting all day long and it's not healthy at all. So if we're able to do, you know, break that up.

David Mizrahi:

There's this concept called exercise snacking, where it's like two or three minutes a time of movement and that can be like going upstairs. And there's some researchers at sydney university, professor manos, stomach attackers, who specializes in this type of work, and just a few sessions of two minutes of vigorous exercise, like going upstairs throughout the day, can lower your cardiovascular and your mortality risk. So even if you're not hitting the guidelines for 30 minutes, just doing a little bit here and there is useful, particularly breaking up the day. And if you don't have time to go out to do a proper session, just doing bits and bobs on the spot can be really quite helpful compared to doing nothing.

Bogda Koczwara:

You've been leading the way in showing in sort of leading by example, because you've been organizing the running group at the annual COSA scientific meeting. I hope there's going to be another running adventure in November at the Gold Coast.

David Mizrahi:

Yeah, I hope so, because Gold Coast it's beautiful. My marathon PB is in Gold Coast. It's very flat, it's beautiful, it's nice beaches. So yeah, we've done a couple of years now at the COSA ASM.

Bogda Koczwara:

Yes, we did Brisbane and then we did Melbourne, which I did in our tent. So I certainly am planning to turn up with my running shoes at the Gold Coast meeting, so hopefully there'll be a running group. I was particularly heartened to learn that one of the biggest cancer meetings, the American Association of Cancer Research meeting, which had a big fun run for charity I think a five-kilometer run so I hope that one day that small meeting that you started is going to graduate into something even more substantial.

David Mizrahi:

Yeah, hopefully. I think we maybe need to play it smarter. I also went to a conference in San Diego. It was the American College of Sports Medicine. They had a big race sponsored by Gatorade, so maybe that's how they got up and running. But there was 400 or 500 exercise people exercise physiologists and sports scientists a very enthusiastic and fit bunch up at the crack of dawn. But it was so nice. You know it's very different. Like people are very different. When you're networking in the professional space In a conference setting, you know you've very different Like people are very different. When you're networking in the professional space in a conference setting, you know you've got your extroverts who dominate in that setting and it's just such a nice way.

David Mizrahi:

When we've done that run, you know, when we did it together that first year in Brisbane, it was just a really good way to get to know each other. All different disciplines. We had people from medical oncology, we had nursing, we had biostatisticians, we had me, and from exercise we had surgeons as well. It's truly multidisciplinary and it brought us all together. So it was, it was a nice way to see the city and to network and you know we can collaborate that way, come up with new ideas so hopefully we can keep growing it and for me particularly that's it's a great culture thing, because I can really continue to promote my cause, which is promoting exercise and cancer care to the people who are delivering those messages to patients, because you guys are all seeing patients, so it's a great opportunity for me to network and go for a run.

Bogda Koczwara:

Yes, go for a run. Yes, so you've just given me an example of an area of supportive care where we can actually not just fix a problem but positively affect the person with cancer and potentially positively affect the person who is doing the caring or healthcare provision for the person with cancer. So quite an unusual and quite an inspiring area of supportive care. So before we finish our conversation, I've got one question, david why, in your view, supportive care matters?

David Mizrahi:

Such a good question. It's everything, isn't it Like we've moved so far away from treatment is the only thing that we're focused on. Obviously, the treatment is saving their lives, but it comes at a cost. The cost of cure is high and there's so many side effects that are caused by the life-saving treatment that patients are prescribed and enter supportive care to find all those ways to help the patient solve the issues that have arisen because of the cancer and treatment.

David Mizrahi:

So supportive care can mean all the adjunct therapies and multidisciplinary teams and nursing and allied health professionals that were once considered a could have, but now it really should be considered a must have when we know that, for exercise at least, patients can live longer, healthier and better lives from being more active. So I think it sort of moves from a patients could want it to patients really could need it. Supportive care is something that I'm grateful to see that it's become a standard part of cancer management and I hope it continues that way that we come with new novel ways to support patients through this horrible disease, and I think we will, because we're a really motivated bunch of us cancer researchers. We're always trying to find ways to improve patient care and I think people like yourselves and all the other researchers in Australia will continue to strive to do that.

Bogda Koczwara:

I think you've captured it very nicely. It's making people better. One walk, one run, one bicycle ride at the time.

David Mizrahi:

Yeah, and one burpee eventually.

Bogda Koczwara:

Yes, and one burpee. I don't know about burpees, david, but thank you, I'll take the burpees or not, that's okay.

David Mizrahi:

Thank you so much, Bob, for having me, and to everyone out there who's seeing patients continue to talk about the importance of exercise. It's really valued by them and certainly one important way to help your patients.

Bogda Koczwara:

Thanks, david, awesome Loved it.

David Mizrahi:

Thank you so much.

Bogda Koczwara:

That is all for Supportive Care Matters, a podcast created by me, Bogda Kozluara, for researchers, clinicians, policymakers and patients passionate about improving the lives of people affected by cancer, Thanks to Mark Tai, who composed the original music, and the Oncology Network, our producers. For show notes, go to wwwoncologynewscomau. Subscribe to this podcast at your favourite podcast provider and rate us. It will help others find us.