Astronauts, Transplant and CAR T-cell Recipients: What Do They Have In Common?

  Download Speaker Slides  

Astronauts, Transplant and CAR T-Cell Recipients, What Do They Have in Common?

Presenter: Jessica Scott, PhD, Associate Member at Memorial Sloan Kettering Cancer Center (MSK) and Associate Professor at Weill Cornell Medical College. 

April 27, 2024

Presentation is 34 minutes long followed by 14 minutes of Q&A

Summary:

Reduced strength and stamina are common after a bone marrow/stem cell transplant or CAR T-cell therapy. Using a model developed for astronauts, it is now possible to measure fitness before treatment, and prescribe an exercise program that can help reduce the decline in fitness after transplant or CAR T therapy.

Key Points:

• Cancer patients experience loss of fitness after treatment similar to the loss astronauts experience during space flights.  
• Exercise training before, during and after a bone marrow/stem cell transplant can reduce the loss of fitness.
• Before beginning a new exercise program, get medical clearance from your doctor, measure your current activity – the steps you take daily – and gradually increase your activity each day.

Highlights:

(04:04): NASA identified several risk factors for side effects astronauts experience during and after space travel: astronauts’ lifestyle and baseline health before the flight such as smoking, being overweight, high blood pressure and high cholesterol; exposure to microgravity and radiation during the space flight; and, most significant, inactivity during the flight.

(07:54): Some of the side effects found in astronauts after space flight were “brain fog”, changes in white and red blood cell counts and decreased heart and muscle size.  

(10:13): After the Gemini space mission, astronauts lost 25% of their fitness, which is equal to almost two decades of aging, in just two weeks. On subsequent missions, they found that exercise 30-minutes per day could reduce the loss of fitness.

(14:31): Cancer patients experience similar loss of fitness after treatment as that experienced by  astronauts.  

(17:23): A study of bone marrow transplant patients found that 25% had a decline in fitness six weeks after treatment.

(19:33): A study at Memorial Sloan Kettering found that three hours of exercise/week reduced the risk of developing a blood cancer by 6%, and the risk of death in blood cancer patients by 26%.

(22:37): It’s never too late to start and gain the benefits of exercise training.

(24:47): Before starting an exercise program, get medical clearance from your doctor.

(26:42): To determine the amount, type and frequency of exercise you should start doing, assess how many steps you currently take each day, and begin gradually increasing that, a little longer each day.

(31:50): It’s best to alternate days of low intensity exercise with days of high intensity exercise to allow your bold to rest and recover.

Transcript of Presentation:

(00:02): [Susan Stewart]: It's my pleasure to introduce to you Jessica Scott, who's going to be presenting the workshop, Astronauts, Transplant and CAR T-Cell Recipients, What Do They Have in Common?

Dr. Scott is an Associate Member of the Memorial Sloan Kettering Cancer Center, and Associate Professor at Weill Cornell Medical Center. Her research focuses on studying exercise therapy to prevent and treat the side effects of cancer therapy.

Prior to joining Memorial Sloan Kettering, Dr. Scott spent five years as a Senior Scientist in the Exercise Physiology and Countermeasures Laboratory at Johnson Space Center, where she studied how to optimize exercise training for astronauts who are on long duration spaceflights. She's prepared this presentation for us and will be available after the talk to answer questions you have. Please join me in welcoming Dr. Jessica Scott.

(01:09): [Dr. Jessica Scott]:  Great. Well, thanks so much. I'm so pleased to be invited to this important symposium, and share some of the work we're looking at, and some of the commonalities between astronauts, transplant recipients, and chimeric antigen receptor (CAR) T-cell recipients. I have no disclosures.

(01:30): Learning Objectives. For today's talk, I have three key learning objectives. The first is to describe some of the side effects of spaceflight, and what astronauts do to try and limit some of those side effects. The second is comparing some of the side effects that astronauts experience, and the side effects that happen as a result of treatment and look at how exercise could limit some of those side effects, and what the evidence is. And finally, I'll go into recommendations, and how you can start exercise training after receiving a transplant or CAR T-cell therapy.

(02:17): NASA’s Countermeasures Program identified side effects of space flight, factors that contribute to side effects and how exercise can mitigate them. Looking first at the Spaceflight Countermeasures Program, as Sue mentioned, I spent a total of seven years at Johnson Space Center, where we studied what some of the side effects of spaceflight were, and what the effects of exercise could do to offset some of those side effects. But before getting into some of that work, I'd like to start with a historical background on how NASA has evolved to sending humans into space.

(02:52): The very first mission was back in the early 1960s, it was a Mercury mission, and that lasted just 15 minutes, but it was successful. So, from that point forward, NASA started slowly and incrementally making the missions longer in duration and going further away from earth. The current missions are International Space Station missions, and they typically last anywhere from 90 days up to over a year in length. NASA is now looking at missions that are up to three years going to Mars.

(03:37): The only reason we can even consider sending humans on these long duration missions back to the moon and onto Mars is because NASA implemented a Spaceflight Countermeasures Program that really consists of two elements. One is looking at what are the side effects of spaceflight? And the second is, what are exercise interventions that can be used?

(04:04): An astronaut’s lifestyle and health before space flight, including smoking, being overweight, high blood pressure and high cholesterol increase the likelihood of side effects in space flight. When looking at some of the side effects of spaceflight, NASA did a very good job, starting back in the 1960s, on what are factors that contribute to side effects, and what are those side effects? They call those the multiple hits.

(04:24): The first hit was a baseline risk factor. I think a common conception is that astronauts are all extraordinarily healthy, superhuman athletes, and there are certainly some astronauts that are like that, but the majority of astronauts typically have a baseline risk factor, and that's similar even going back to the Pioneer missions in the 1960s.

(04:55): Looking at the picture on the left, first in the Pioneer mission, the average astronaut age was fairly young. They were 37 years old, but four out of the seven astronauts were smokers, and three of them were worried about their weight, so they were overweight.

We fast-forward to the current era, or the International Space Station missions, the average astronaut is a 49-year-old male, who has a cardiovascular risk factor, whether that's high blood pressure, high cholesterol, or being overweight. So that's part of the first multiple hits.

The second multiple hits are what we call a direct hit. And this is primarily a result of microgravity, or the radiation that astronauts are exposed to on these missions.

(05:55): Factors during space flight that cause side effects include exposure to microgravity and radiation and, most significantly, a lot of inactivity during the flight. With regards to microgravity, the majority of our blood is in our lower body, but as soon as astronauts go into space, there's no gravity, so there's about two liters of fluid that moves from the lower body, to the chest, and the head. You can see that in these two pictures. On the left is astronaut Chris Hadfield on earth, and on the right is Chris in space, where you can see he gets that puffy face syndrome, and his blood vessels in his forehead are a little bit bigger, and that's because of all the fluid shifts that happen when you go into space, and those fluid shifts cause a lot of changes to the cardiovascular system in particular.

(06:46): The third and final hits are what we call an indirect hit. This is actually probably the most impactful hit for astronauts. In space, there are no steps, there's no activities of daily living, so astronauts are exposed to a lot of inactivity, and they may gain weight or lose weight.

(07:11): For example, in the Pioneer missions on the left, that is a picture of a Gemini capsule, where astronauts were in a very confined space for up to two weeks in duration. And you can't move around a lot, so they have a lot of changes in all of their body systems. On the right is the picture from the current era, International Space Station missions, where astronauts have more room to roam around, but the way that they move around is mostly by using their arms, so their legs also become very out of condition.

(07:54): Some of the side effects that astronauts complain about are space fog, or their brain feels a little bit fuzz, changes in white and red blood cell counts, and decreased heart and muscle size.  When you take those multiple hits together, the baseline risk factors, direct and indirect hits, they impact every single system in the human body. Some of the side effects that astronauts complain about are space fog, or their brain feels a little bit fuzzy. They have changes in white blood cell and red blood cell counts, their heart size and muscle size decreases, bone changes. A whole host of changes to the human body.

(08:28): NASA noticed that these changes were occurring, and they were very interested in different ways that they could evaluate multiple systems at one time. So back in the 1960s, they decided to test astronauts using an exercise test to look at their fitness.

(08:49): This exercise test is a great way to look at multiple systems at one time. Typically, it's on a treadmill. You increase the speed and grade until astronauts reach maximal effort. And why this is so nice is that it's a very short test, it only takes about 8 to 12 minutes. You can look at multiple systems at one time when you're exercising, like your heart, even lungs and your muscles. And then the final aspect is, this test has been around since the 1920s, so there are very well-established normative values.

(09:34): And this graph highlights some of those normative values. In blue, individuals who are endurance-trained typically have a little bit higher fitness. In the dotted orange line, those are active individuals, so generally active a little bit lower than endurance trained. And in red are individuals who are not as active. And what we can also see with this graph is that, as we age, even if you are endurance training and training for marathons, we typically lose about 10% per decade.

(10:13): After the Gemini space mission, astronauts lost 25% of their fitness, almost two decades of aging in just two weeks. On subsequent missions, they found that 30 minutes of exercise per day could reduce the loss of fitness. NASA knew that there was about that 10% per decade loss of fitness with healthy aging, and they wanted to evaluate what happens when astronauts go into space. And reading some of these older documents, it's very interesting to note that clinicians and researchers were a little bit surprised that after just 14 days of spaceflight on a Gemini mission, astronauts returned having lost 25% of their fitness, so almost two decades of aging in just two weeks.

(10:54): And what NASA noted, again, this was in 1964 before NASA was going back to the moon, they really decided that that amount of decline was unacceptable for human missions to the moon. They were worried about sending astronauts to the moon, and having them locomote, and gather the lunar rocks, and how would they be able to do this if they had lost that much fitness? They knew they needed an intervention, and rather than turning towards certain drugs that might be able to target a single system, they decided to try exercise training, because it can target multiple systems at one time.

(11:42): This is an image of the very first exercise session performed in space. It was on a Gemini mission in 1965. And they had the two astronauts that were on this mission, completed three 10-minute exercise sessions per day, about 30 minutes in total, interspersed throughout the day. And they were really impressed reading through these documents again. Compared to the prior mission, where those astronauts had lost 25% of their fitness, just doing 30 minutes of exercise per day really limited how much fitness astronauts had lost. So, they concluded that there is a real need for an exercise regimen on longer duration spaceflights. And this line of research really cascaded over the next fifty or so years, and a lot of research was devoted at NASA to try to understand how astronauts can exercise in a fairly toxic environment of spaceflights.

(12:58): Fast-forwarding to exercise on International Space Station missions, again, the missions are anywhere from six months up to 12 months in duration, and exercise is mandatory. It’s scheduled for about 80 minutes per day, six days per week. The NASA engineers design some pretty incredible exercise equipment to allow astronauts to be able to exercise while they're on International Space Station.

(13:33): On the left is a treadmill where astronauts, they bungee themselves down, otherwise they would float away while they're trying to run on a treadmill, but this treadmill can do walking exercises, as well as running, or higher intensity exercise as well. And on the right, we have the advanced resistive exercise device. And what's interesting about this device is, it can do basically any exercise you would do in the gym on earth, astronauts can do in space. It can be reconfigured to do bicep curls, or squats, or leg extension exercises, all of those very important exercises for trying to help to maintain muscle mass while astronauts are floating around in space for up to a year in length.

(14:31): Cancer patients experience the same loss of fitness after treatment as astronauts do on space flights: brain fog, changes in blood cell count, decreased heart and muscle size, and gastrointestinal problems. That was a very quick overview of NASA's Countermeasures Program. Now let's look at how the Cancer Countermeasures Program could parallel what NASA has done. I was at a conference, and speaking to one of my colleagues, and describing some of the multiple hits and side effects that astronauts experience, and she mentioned, "Boy, that sounds a lot like what patients experience who have received treatment for cancer therapy." And it turns out that there are very similar multiple hits.

(15:12): At diagnosis, for example, a patient may have one of those cardiovascular disease risk factors, such as high blood pressure or high lipids. The direct hits are different between astronauts and patients. With patients, the direct hit is typically those systemic therapies, chemotherapy or radiation. And then that third hit that is really important but is often lost because the focus is so much on the chemotherapy or the radiation, are the effects because patients don't feel as well while they're receiving therapy, so they become less active, and they may gain weight or lose weight. All of those hits together result in very similar side effects between astronauts and patients, where there are commonalities with brain fog, and changes in blood cell count, decrease in heart size and muscle size, gastrointestinal events, all very similar between astronauts and patients with cancer, obviously to varying degrees.

(16:27): But in patients with cancer, this is where, given those similar side effects, we can start to take a similar approach to what's been done at NASA, and try and understand what are those side effects, and how can we try and offset those side effects?

(16:46): One of the first aspects that we were interested in testing was that fitness test. So just like NASA did back in the 1960s, what happens after undergoing bone marrow transplantation, or receiving different chemotherapies. So, patients will do the exact same test as astronauts to look at fitness. This is an eight-to-12-minute test, where we're looking at multiple systems at one time, and comparing that to normative values.

(17:23): A study found that six weeks after a bone marrow transplant, there was a 25% decline in fitness. Just to remind you of what we've seen with normal aging, it's about a 10% decline. But spaceflight back in 1964, again, there was that 25% decline, and then a few years ago a trial looked at what was the change of fitness after bone marrow transplantation? After six weeks, there was about a 25% decline in fitness. So very similar to what astronauts experienced back in the '60s, where there's this accelerated aging, so almost two decades of physiological aging after just six weeks. So that really highlights the need for interventions to try and offset some of those declines.

(18:16): And I was also really interested to see and learn that exercise is standard of care for individuals with different chronic diseases, like heart disease, or chronic obstructive lung disease, it's standard of care in astronauts. But when I joined Memorial Sloan Kettering about seven years ago, exercise was not standard of care for any individual with a cancer diagnosis. And that's what really drove me to look at some of the evidence on how exercise could be helpful in different cancer settings.

(18:56): One of the first areas that we look at is whether exercise is helpful in either cancer prevention or decreasing the risk of death from any cause. This was a study we recently published, where we looked at over 10,000 individuals with different cancer types, and looked at whether if individuals reported doing just three hours of exercise per week, was that associated with a reduced risk of cancer incidence?

(19:33): A study at Memorial Sloan Kettering found that three hours of exercise per week reduced the risk of developing a blood cancer by 6%, and the risk of death in patients with a blood cancer by 26%. And it was. On the left, for certain cancer types, about a 20% reduction for lung cancer, 11% for breast cancer, and about a 6% reduced risk of even developing different types of blood cancers. And on the right, we looked at deaths from any cause. And here, there is much greater risk reduction in different cancer types. About a 24% reduced risk in breast cancer, 22% in prostate cancer, and impressively about at 26% in patients that have been diagnosed with different types of blood cancers. So, this is the first line of evidence suggesting that exercise could be beneficial in preventing some of those long-term events that happen years after receiving treatments.

(20:34): Exercise before, during and after a bone marrow/stem cell transplant can significantly reduce loss of fitness. There are some trials that have looked at exercise training during and after transplantation. This was a trial that randomized patients into two different groups. One group completed a supervised exercise training session, where they exercise trained about 21 days before transplantation, they then have 45 days in hospital, where they performed exercise training, and then post-transplant, they also continued the exercise training. And the other 53 individuals, they were randomized to do usual care, where they just completed some physical therapy sessions while they were in hospital. And what this study found, they were looking at fitness, so that exercise test, they found that exercise training was really important throughout the transplantation process.

(21:36): So, looking at this graph, the exercise training is in blue, and the usual care is in orange. So even just doing 21 days before transplantation of exercise, patients were able to increase their fitness. In the time point immediately right before they were discharged from hospital, they did another exercise test, and it declined a little bit in the exercise training group, but much less than in the usual care group. And importantly, in that post-transplant, about 50 days after the transplantation, the exercise training was associated with an increase in fitness compared to baseline levels. So really showing that exercise training can be very important for offsetting some of those accelerated aging that we see in body as a result of the different types of therapy.

(22:37): It’s never too late to start and gain the benefits of exercise training. We can also see from some of the evidence that it's never too late to start exercising. This was a study we did looking at adult survivors of childhood cancer. And we asked these individuals how much exercise you do at one time point, and then about eight years later, we asked what their levels of exercise were. And what we found was that, compared to those that maintain low levels of exercise, individuals that reported increasing their exercise levels, even by just as little as about 30 minutes per week, they had almost a 40% reduced risk of death from any cause. And that was similar to those individuals that reported maintaining high levels of exercise over those eight years. Again, really strong evidence showing that exercise training can be very important, and it's not too late to start exercising, and just to start a little bit is better than nothing.

(23:48): Looking at a summary of the evidence so far, this looks at the change in fitness. The blue line represents that normal age-related decline that we see. And the red line represents what happens as you progress through your treatment continuum. We know that exercise can decrease the risk of cancer incidence by about 10 to 20%, depending on the cancer type. During treatments, exercise can improve fitness up to 10%. If you exercise after the completion of treatments, you can improve your fitness even more, anywhere from 10 to 20%. And in that post-treatment setting, we know it can reduce the risk of other diseases, particularly heart disease in individuals who have received a transplant.

(24:47): Before starting an exercise program, get clearance from your physician. The final area I'll go into after that evidence is, what can you do to start an exercise program? The very first step is medical clearance. Ask your physician or your clinician, "Is it safe for me to start exercising?" if you have not been exercising in the past. And they may have you do different tests to look at medical clearance. They may have you do an exercise stress test; they're very similar to that test that astronauts do, where it's just an eight to a 12-minute test, where the treadmill gets progressively harder, and you go for as long as you can. They may also do an echocardiogram to look at your heart function and your heart size.

(25:41): Once those have been cleared, the next step is to look at, what are your current activity levels? This is always a bit of a challenge to accurately assess what your current activity levels are, but fortunately, we live in a world where there are a lot of devices, and even if you have a cell phone, or an activity watch, it gives you a very good idea of what your number of steps are per day. A great way to look at this is, over the past month, what are the average number of steps that you've taken per day? And based on that, there are different ways, and different time points, on how you should start exercising. Because if you're currently not taking a lot of steps per day, you don't want to try and start out right away with a 10,000 steps activity level.

(26:42): To determine the amount, type and frequency of exercise you should start doing, assess how many steps you currently take each day, and begin gradually increasing that, a little longer each day. And depending on the number of steps that you've looked at over the past month or so, you can get an idea of what your starting levels are. If you're not currently active, and this would be for individuals that are doing less than 1,000 steps per day, we recommend the FITT principle, which is frequency, or how many times per day, intensity is, how hard does it feel? The time is, how long should the exercise session be? And the type is the modality of exercise that you should do. So, for individuals doing less than 1,000 steps per day, we recommend starting by doing 30 seconds to one minute of exercise, so they're very short, and throughout the day, trying to do those different amounts of exercise. Walking, taking the stairs, this could be parking a little further away while you're going to the grocery store, so you get a little bit more of continuous exercise.

(28:02): If you're doing 1,000 to 3,000 steps per day, the goal is to increase the time that you're doing continuous exercise. So again, it's several times throughout the day, trying to do 5 to 15 minutes of exercise at a moderate intensity. Again, this can be done through walking, stairs, biking, different modalities, where you're doing continuous exercise for a little bit longer sustained periods. As we progress to, if you're already doing 3,000 to 7,000 steps per day, this is where the duration or the time gets a little bit longer. We go anywhere continuously from 30 to 45 minutes, and at least one to two days per week of trying to get those 30 to 45 minutes in. And if you enjoy doing resistance training, this is where you can start incorporating some resistance exercise as well, once you're at that sustained level of exercise.

(29:12): For those that are already active, so this is you're already doing 7,000 up to 10,000 steps per day, here, the frequency is higher, so going for 3 to 5 days per week of exercise of 30 to 40 minutes. Again, aerobics and combined resistance training if that is what you're interested in. And then finally, if you're already very active, you're already training for different events, whether it's cycling, or running, or swimming, this is where you can start to increase your intensity. The frequency is 3 to 6 days per week. Your intensity can now be from moderate to high intensity, and the time is a little bit longer as well, anywhere from 30 to 60 minutes of exercise.

(30:09): I'd also like to make a note about exercise intensity. Now, typically, we will design programs based on that exercise test, where we can look at what your peak heart rate is, and what your different time points are, and we give different zones. So, this, on the right, gives an individualized exercise prescription. I often get asked, "Well, you can't expect me to train like an astronaut." And that's certainly true, but we use a very similar program, where either an astronaut or a patient will be given five different intensity zones.

(30:55): Now, the astronaut may have a higher speed or a higher grade on the treadmill than a patient, but they're still doing high-intensity and low-intensity sessions. To give you an example week with four different sessions. What is commonly prescribed is a linear moderate intensity. So those are the yellow bars on the left, where every single session within a week is pretty moderate intensity, so where you're starting to breathe a little bit harder. An alternative program that sometimes has been brought to our attention is what's called a linear high intensity. This is where every single session is done at interval type, or near maximal efforts.

(31:50): It’s best to alternate days of low intensity exercise with high intensity exercise to allow your body to rest and recover between sessions. But what we recommend, and what astronauts use, and what we use with our patients is called a nonlinear program. And this is where they alternate days between lower intensity days and higher intensity days. The black bar is a very easy day, the gray bar is a little bit of a harder day, and then it backs off to the blue and the yellow bar. Every day is a little bit of a different intensity, and that's very helpful in allowing your body enough time for rest and recovery between sessions, and that's what we've found has been really helpful in particular for improving fitness.

(32:37): That's a quick overview of what our group does for recommending exercise training. There are other sources of information available, and there are certain centers that provide supervised exercise training. So, for example, there is something called the LIVESTRONG at the YMCA, where they have certified professionals who can work with individuals who have been treated for cancer. There are also local gyms, they have individuals who have specialized training for working with individuals who've been treated for cancer. And then there are other online sources available, in particular from the American College of Sports Medicine, and there's the National Comprehensive Cancer Network, and then standard guidelines for other general recommendations as well.

(33:38):  To summarize, we know that exercise is very important for reducing cancer incidence and death from any cause, and it can help offset and reverse some of those side effects of cancer treatments. There are three steps to starting an exercise training program, you get medical clearance, accurate assessment of what your current activity levels are, and then choose your exercise training program based on your steps, or your current activity level. And then finally, try and follow the FITT principle. Looking at the frequency, the intensity, and the time, and type of exercise that you do. With that, I'd like to acknowledge our team at Memorial Sloan Kettering. I'd like to thank you again for the invitation to speak at the symposium, and I'm happy to answer any questions.

Question and Answer Session

(34:38): [Susan Stewart]:   Thank you so much, Jessica. That was really a fascinating overview of what the comparison is between astronaut experience and cancer survivor experience. We certainly sometimes feel like we're shot into space, and I'm glad to see the evidence indicates that we're not lying. We have a couple of questions, if you could answer them. We actually have quite a few, so let's start. “Can you comment on the vibration platforms to enhance the effects of exercise training? Are those helpful?”

(35:16): [Dr. Jessica Scott]:   That's a really great question, and I know that the vibration platforms are really helpful for certain systems. For example, bone. We know that with different types of therapies, there's bone loss, and that's an important concern, particularly for older women. And there have been some studies that have shown that adding vibration training can be very helpful for offsetting osteoporosis or osteopenia.

(35:50): [Susan Stewart]:   Great. Next question is, “Does the exercise program you discussed for each person, is that based on his or her exercise stress test that you showed earlier? And if so, is it easy to have the test done by a physician? And if so, what kind of physician?”

(36:09): [Dr. Jessica Scott]:   Yeah, that's another great question. At our institution, we have patients that get referred to do a stress test, and from that stress test, that's how we design the individual intensities, or the different zones that they do. It depends on your physician. You can ask your physician for, when you go to get medical clearance, if they recommend doing a stress test. That's how you can get that stress test done, and you can get your heart rate zones, and look at different intensities that way. If you're not able to have a stress test done, but you're still cleared by your clinician to start exercising, there is an age predicted maximum heart rate formula that is also very helpful when you're looking at different training zones that can be used.

(37:11): [Susan Stewart]:   “I'm on drug therapy that causes shortness of breath. What exercises can I do?”

(37:21): [Dr. Jessica Scott]:   That's a great one. And again, one of the best ways to exercise is starting with walking. And given that you're on a drug that causes shortness of breath, even doing lower intensity, or walking on a flat surface, that's really helpful for starting that training process, and gradually increasing how long you're able to go, and gradually increasing, if you incorporate a hill in your outside walks for example. But it's really important to start out in an area where you can take a rest if needed. So, it's shorter sessions at the start, and maybe just a minute starting out, and then gradually trying to make it a little bit longer every time.

(38:21): [Susan Stewart]:   The next question is from somebody who likes to ride a recumbent bike, "I'm going to have a donor stem cell transplant in a month and a half, and I'm currently taking about 1,000 steps per day. What schedule should I follow in terms of time and difficulty on a recumbent bike?"

(38:41): [Dr. Jessica Scott]:   That's a great way to get exercise in, is a recumbent bike, particularly if you are having challenges with doing any walking. The recumbent bike is so great, because you're able to get your blood flowing, get your heart pumping, get your muscles working, but it doesn't cause that added stress of being in that upright position. So, I really do recommend that the recumbent bike is incorporated, and that's a great way to start training. It would be very similar to getting the duration and the frequency in with the number of steps. So, it would be starting out with the short timeframe of exercise. If you're able to do five minutes continuously, that's great, and then slowly and gradually increase the amount of time that you continuously cycle on that recumbent bike. But that's such a great comment, that starting with different types of exercise training is also really helpful.

(39:53): [Susan Stewart]:   “Does yoga play a role in exercise fitness?”

(40:01): [Dr. Jessica Scott]:   Yoga is another really important one, particularly for some of those side effects, and improving fatigue. There have been several studies showing that, particularly the mind-body studies, that interaction, and yoga has been very important in offsetting some symptoms like fatigue or difficulty sleeping. And yoga is a great way to start to increase the activity levels with lower intensity. So again, the yoga would be one of the lower intensity exercise sessions to start with, and then gradually start incorporating some walking, or biking, or swimming that will increase your heart rate. But yoga is certainly a great way to get started.

(40:56): [Susan Stewart]:   This person noted correctly that after treatment it's challenging to exercise, even if you're having a good day. “What does a cancer survivor do to get motivated to do the exercise routine you recommend?”

(41:15): [Dr. Jessica Scott]:   It's certainly a challenge to get motivated to even start. We recommend a couple of different aspects that might be helpful. One of them is finding a partner who would be interested in starting exercise training. Whether that's another individual who is post-treatment, one of your family members that is really motivating, is to have somebody start that exercise training program with you is really helpful. And the second component is that you need to remember that you don't need to start trying to get those 10,000 steps per day, it's really small bites, or you can even call them exercise snacks, where it's just tiny little bits of extra steps, or extra exercise in your day, and that will gradually become routine, and then you'll be able to start doing some longer sessions. But it's really starting with small bites, and every day is a new day, and just increasing any exercise, taking the steps, parking a little farther away. We've found that helpful.

(42:40): [Susan Stewart]:   The next person wants to know, “If you are following the FITT program, how do you know when to switch to the next higher level? For example, from level one, 1,000 steps a day, to the next higher level?”

(42:55): [Dr. Jessica Scott]:   Another great question. We typically say, once you're able to complete one level for three or four weeks, then you're ready to go on to the next one. We know it takes a little bit of time to adapt to a new exercise program, either if you're just starting out, or if you're increasing the volume of exercise. We really recommend giving it at least 3 or 4 weeks before you try and increase it. Just like the other individual asked, there's always good days and bad days, and that's okay, you just keep trying the next day. And sometimes your body just needs rest and recovery, and then on the days that you're feeling good, you can try and push it a little bit more.

(43:47): [Susan Stewart]:   This person wants some quick clarification, “Are the exercise times in the FITT model, are those minutes per session?”

(44:00): [Dr. Jessica Scott]:   Correct. So those are minutes per session. If you add up the number of days per week, and the time, you'll get the volume in a week. You might hear from general guidelines, or exercise recommendations that you should get 90 minutes per week of exercise in, or 75 minutes per week of exercise in. We typically break it down by exercise session. If you're doing three exercise sessions of 30 minutes each, that's 90 minutes per week.

(44:41): [Susan Stewart]:   “I heard it takes seven days of active life to make up for one day in the hospital. Is this true? And if I were in the hospital for a month, how long would it take me to get back to my pre-admission level?”

(44:58): [Dr. Jessica Scott]:  That goes right along with the accelerated aging that we see with the fitness. I don't think there's been any studies that have actually quantified it other than fitness, that after six weeks after bone marrow transplantation, there's about two decades of aging. So that might be pretty close to what happens. And we hear all the time, patients say, "I feel like I've aged 10 years." And we can measure that as well. And how long it takes to recover after that has also not been quantified, but we know that as soon as you're able to start, the quicker the recovery will be. The quicker you're able to start doing either the recumbent cycling is a great way to start, or getting more steps in, that recovery time will be quicker than if you wait a longer period before starting an exercise program.

(46:07): [Susan Stewart]:   “Would you approach children in transplant the same way as you would approach adults in transplant as far as exercise training?”

(46:20): [Dr. Jessica Scott]:   That's another great question. And there's been wonderful work out of St. Jude's, who have done exercise training in children who have received transplants. And it's a little bit of a different program with kids, because they are more interested in play-based activity. And they've shown that doing some play-based activity, either with video games like Wii, that's very helpful in trying to limit some of those declines that happen as a result of treatment. And with adults, we can take a little bit more a structured approach than we do with kids.

(47:05): [Susan Stewart]:   So, we have a lot of questions remaining, and unfortunately, we don't have time to answer them all. I'll choose this last question. “Can an exercise program completely reverse the advanced aging effects?”

(47:22): [Dr. Jessica Scott]:   Yes, is my final answer. We've shown in various settings, and all of the evidence so far suggests that you can reverse that aging, and it's so important for offsetting some of the late effects that happen years after treatment. And my final takeaway is that it's never too late to start, and there's never too little to start exercising.

(47:54): [Susan Stewart]:   Great. Well, on that note, I'm afraid we’re going to have to end this session. On behalf of BMT Infonet and our partners, I'd like to thank Dr. Scott for a very thought-provoking presentation. And to thank you, the audience, for the excellent questions that you submitted. Please contact BMT Infonet if there's anything more we can help you with. You can use our email at help@bmtinfonet.org.