Breast Cancer Lump Symptoms

[wendy nilsen] good afternoon everyone. thisis wendy nilsen from the office of behavioral and social sciences research here at the nationalinstitutes of health. welcome. this is going to be a really exciting and informative webinarand i know you're really going to enjoy it. i'm going to spend a second introducingour speaker, but i know you don't want to hear me, you want to hear her. so i'm goingto introduce laura rogers. and she is a professor in the department of nutrition sciences atthe university of alabama at birmingham. and as she's going to tell you, she's doneabsolutely amazing work in diet and activity with women with breast cancer. and like isaid, you don't want to hear me, you want to hear, you want to, definitely want to heardr. rogers. so with that i'm going to give

it to her. [dr. rogers] thank you. [wendy nilsen] thanks for being here. [dr. rogers] thank you for that nice introduction.it is an honor and pleasure to be here today wendy. during this presentation i will bediscussing the importance of physical activity adherence after a breast cancer diagnosis.i want to review the excellent progress that's been made in the field as it relates to designingand testing interventions to improve physical activity adherence in breast cancer patients.and then also discuss future directions with a special emphasis on concomitant chronicdisease conditions.

first in regard to the importance of physicalactivity adherence after a breast cancer diagnosis. this is one example of several studies thathave looked at the association between exercise post-breast cancer diagnosis and breast cancerrisk. and this particular study, it was a meta-analysis of 6 studies and for the purposesof application, i have converted the original units of met hours per week to the numberof hours of moderate intensity walking per week. and this meta-analysis, it revealedthat for breast cancer survivors who were doing 1 to 3 hours per week of activity equivalentto moderate intensity walking, had a 20% reduction in their risk of breast cancer recurrencewith those engaging in 3 or more hours a week, having a reduction in risk of 35%. a similarpattern is seen with regard to the breast

cancer mortality risk. with those women engagingin 1 to 3 hours per week of activity demonstrating a significant reduction in risk of breastcancer mortality with an even greater reduction of 46% for those doing at least 3 hours perweek of the activity. so it's important that breast cancer survivors engage in regularphysical activity after their breast cancer diagnosis. there are several studies thathave demonstrated that a majority of breast cancer survivors are not meeting current recommendationswhich are generally at this point recommended to be at least 150 minutes per week of moderateintensity exercise or 75 minutes per week of vigorous intensity exercise. this is one example of a study that has lookedat the prevalence of meeting recommendations

among breast cancer survivors. this is a multi-ethnicsample from 3 u.s. states and it revealed that only 34% of the breast cancer survivorswere meeting exercise recommendations pre-diagnosis. only 34% were meeting these recommendationsat 24 months post-diagnosis. 40% were meeting it at 5 years and only 21% were meeting theserecommendations at 10 years post-diagnosis. given the importance of physical activityafter a cancer diagnosis, the national comprehensive cancer network has added exercise, or includedexercise recommendations to their recently released survivorship guidelines. these survivorshipguidelines are not breast cancer specific. they are appropriate for all cancer types,but the important thing is that the nccn is considered a go-to resource for many oncologyhealth care professionals for determining

appropriate clinical algorithms. and in therecent survivorship guidelines it is recommended that the oncology health professional assessthe current physical activity level and limitations of physical activity among the cancer survivors,encourage physical activity as soon as possible after the diagnosis, tailor recommendationsto abilities and preferences. and then it provides general recommendations of encouragingthe cancer survivor to engage in at least 150 weekly minutes of moderate intensity or75 weekly minutes of vigorous intensity physical activity with strength training 2 to 3 daysa week, with stretching on days other exercises are performed. the important thing about these guidelinesis that what continues to raise awareness

among oncology health care professionals aboutthe importance of physical activity adherence after cancer diagnosis. and i think this isan opportunity for future direction as far as integrating interventions into the clinicalcare infrastructure. now as part of those guidelines, strength training is mentionedand it's recommended 2 to 3 times per week. this is a study that looked at the prevalenceof doing any strength training among breast cancer survivors. this took place in australia.we don't have as much information about the prevalence of this particular activity,the resistance training, but in this particular sample, the adherence to strength training,doing any strength training at all was half that of engaging in aerobic activity. so thisis, the point of this slide is to demonstrate

that focusing on resistance training adherenceis an important aspect that we have, that we need to deal with in the future. as partof the nccn survivorship guidelines there is a risk stratification recommended to helpthe health care professional provide the required, or the appropriate recommendations. and theydivide individuals into low-risk, moderate-risk, high-risk, or other. the low-risk are thoseindividuals with an early stage cancer, high baseline of physical activity and no significantcomorbidities and it is recommended that these individuals be given the general recommendations.for those individuals in the moderate-risk, these are individuals who have peripheralneuropathy, musculoskeletal issues, bone mets or poor bone health. and the recommendationhere is to recommend general recommendations,

but also consider whether medical evaluationor referral to a trained exercised personnel is needed. high-risk is defined as individualswith lung or major abdominal surgery, ostomy, cardiopulmonary comorbidities, lymphedema,or extreme fatigue. and it's recommended these individuals have medical clearance andconsider a referral to trained exercise personnel. there are individuals who it is recommendedthat they avoid physical activity. these are individuals with severe anemia, individualswho are immediately post-surgery, who have worsening of their physical condition, oran acute infection. this risk stratification is not specific to breast, it is appropriatefor all cancer types. important thing about this risk stratification is that it includes,you know, comorbidity as a part of the definition

for the various risk strata. so that's partof the reason why there's a special emphasis on concomitant chronic disease states in thispresentation. so i want to talk a minute about one way tolook at the cancer, chronic disease, and physical activity interface. one of the reasons whyi wanted to talk about this is the adherence network is the trans-nih initiative and it'snot, you know, focused on one particular disease state. so as i see it, chronic disease andcancer often share risk factors and i'll show you an example of that. in addition,cancer can either exacerbate or cause a chronic disease. and in addition to that you havephysical activity adherence which could improve a chronic disease or perhaps reduce the riskof a cancer. and then there's also the fact

that the chronic disease and possibly cancercan impact physical activity adherence. lay on that the teachable moment of a cancer diagnosisand you have an opportunity to potentially intervene not only on their cancer risk buton concomitant chronic disease conditions as well. this is a study, a u.s. nationalstudy looking at the prevalence of chronic disease conditions among long-term cancersurvivors versus those without a cancer history. as you can see, there is a higher prevalencein the long-term cancer survivors of arthritis, asthma, coronary heart disease, diabetes,hypertension, and stroke. some of this higher prevalence could indeed be related to ageas you can see that a much higher number of long-term cancer survivors were 65 years ofage or older.

the rate, prevalence of smoking was equivalentin the 2 groups and that prevalence of 19% is a number i'll mention again a littlebit later. so this is an example of how there can be shared risk factors. if you look atchronic disease, a shared risk factor as far as chronic disease and cancer especially withregard to cardiovascular disease. some of the shared risk factors include age, poorphysical activity and diet, excess body weighty, metabolic dysregulation, inflammation, andpossibly hormonal deprivation. it's also possible that cancer treatment can cause achronic disease as demonstrated by this example, which is the cardio toxicity or the increasedcardiovascular disease risk that may result from anthracyclines, her2 antibodies, directedmonoclonal antibodies, or endocrine therapy.

in addition, this is an example of how cancertreatment might exacerbate a chronic disease. in this case it's because of a decreasedability to do self-management for diabetes. in this study they asked diabetic patientsto complete a self-care inventory and at baseline, before chemotherapy, the score is 51 and itsignificantly dropped to a score of 46 at 8 weeks. so those are just a few examplesthat fit within this paradigm of the interface between cancer, chronic disease, and physicalactivity. and as we talk about physical activity behaviors change in breast cancer survivors,i'll be talking some about this chronic, concomitant chronic disease. dr. courneya has described 3 different typesof exercise trials. behavior change trials

are those trials in which the primary outcomeis the exercise behavior. efficacy trials are those in which the primary outcome isthe health outcome. and an effectiveness trial is, the primary outcome is the health outcome,but these usually involve behavior change as part of the trial. for the purposes offocus during this presentation, i'm going to focus on the behavior change trial only.a couple of caveats when it comes to doing that is the distinction between exercise behaviorchange, efficacy, and effectiveness trials may not always be clear. and in the interestof time, i chose to focus only on studies that were done on adults, breast cancer specifically,that were randomized controlled trials and that were testing physical activity adherenceor behavior change studies that were not weight

loss trials. i found 11 of these trials, i'mgoing to spend a minute on this slide that will make it a little bit easier to followthe rest of the slides that follow. this first study, and i put these in the order, the orderin which they were published, so this first study was published in 2004 by lee jones andit compared the effect of having a physician deliver a standard recommendation in clinicversus having the physician deliver the same recommendation plus a referral to an exerciseprofessional versus usual care. and in that intervention, they did demonstrate a significantimprovement in the short-term physical activity adherence for those who received a physicianrecommendation only. the second trial is a move forward trial by dr. pinto. this is a12-week trial that included a pedometer, print

material, one in-person visit, telephone counsellingand feedback. and in this study, she was able to demonstrate a significant improvement inshort-term physical activity adherence by self-report, but not by accelerometer. thethird trial was a 6-month trial that involved 21 lifestyle group sessions, unfortunatelythis study was not able to demonstrate a significant improvement in physical activity adherenceby self-report. but they did see an improvement in some of their physical functioning measures.the next, this fourth study was a 12-week study in which they used a pedometer, print,one in-person visit, and telephone counselling. and they were able to demonstrate significantimprovements in physical activity adherence both by self-report and accelerometer. thisstudy by dr. vallance was a 12-week study

in which he compared a standard recommendationversus targeted print material versus pedometer with a step calendar versus a print plus pedometer.this is a particularly interesting trial and i'll be giving you some additional detailson the results of that in a few minutes. but this study demonstrated a significant improvementin the self-report physical activity, but was not able to demonstrate that the increasein pedometer steps was significant. let's see, this next intervention includedthree 6-hour workshops that occurred over a 3-month period. some individual feedbackwas provided between the second and third workshop and they demonstrated significantimprovement in physical activity post-intervention. this is a study done out of our lab. thisis a pilot study and it's a 3-month intervention

in which individuals received both individualand group sessions as well as print materials. the individual sessions are initially supervisedsessions with exercise specialists and eventually they are transitioned to home-based exerciseand just come in for individual face-to-face counselling sessions. they also come to groupsessions 6 times to discuss behavioral modification techniques. we were able to demonstrate asignificant improvement of physical activity post-intervention based on accelerometer.this is a study, the next study was out of korea. they used telephone counselling over12 weeks delivered by nurses, tailored to stage of change. they also had a workbook.although they did not see a significant improvement in self-report physical activity adherence,the p value was 0.08. and beat + resistance,

that was out of our lab. we used the originalbeat cancer pilot intervention, but we also added to that resistance band. which is importantbecause none of the, of these 11 studies, none have reported the resistance exerciseadherence, nor have they focused on resistance training so i'm going to show you our datarelated to that and just, you know, in the future directions i think we need to lookfurther at resistance training. recently a group has done a 12-week interventionwith emails and access to an e-counselor and this group was able to demonstrate a significantimprovement in physical activity based on self-report. and then lastly dr. pinto'sgroup combined physician advice with a pedometer and telephone counselling and demonstratedsignificant improvement in post-intervention

physical activity based on self-report. thereare a couple of take home messages from this slide. number 1, of these 11, 9 have beenhome-based with only 2 combining the supervised with the home-based options. they have useda variety of components that are varied from physician recommendation to pedometers, telephonecounseling, workshops, print materials, emails, so there's quite a variety here of thingsthat have been tried. for the most part, the short-term or immediate post-interventionadherence has been good and we have very little focus on resistance training up to this point.this is dr. vallance's trial in which he compared the standard recommendation withprint material, with pedometer plus step calendar, with the print material plus pedometer plusstep calendar. just to review the slides for

those who may not be looking at a screen,at this point the print materials although the mean increase from baseline to post-interventionand self-reported minutes of physical activity was 70 compared to 30 for the standard recommendation,the difference between these groups is not significant. the mean increase in minutesof physical activity for the pedometer plus step calendar was 89, which was significantlydifferent from the standard recommendation group. and the print material plus the pedometermean increases 87 and it was also significantly different from the standard recommendation.and the take home message from this slide is that the pedometer is, i think, a veryeffective tool that we need to continue to integrate into our interventions going forward.

the beat + resistance intervention in whichwe gave individuals a resistance band and supervised their training initially and thensent them home to do the training at home. what we found is that the percent of recommendedsessions completed during the entire 12-week intervention overall was 87.5, but if we lookjust at the last 4 weeks which was the home based version, it was only 63%. and the averagenumber of sessions per week during the 12-week intervention was 1.8 and during the last 4weeks it was only 1.3. if you compare these same 11 studies with regard to whether theymeasured longer-term adherence, we see that about half of them did not measure longer-termadherence and of those who did, we do have 2 studies that have demonstrated significantimprovements in physical activity longer-term

and not just post-intervention. with one ofthose demonstrating this, these improvements by accelerometer. i thought it was interestingthat, to compare these with regards to the integrated, the intervention into clinicalcare primarily because of the rising interest among the oncology field for exercise aftera cancer diagnosis. and we do have 3 possibilities here. the initial study by jones related tophysician recommendation, the group in korea who had the nurses doing the telephone counselling,and then dr. pinto's work. as far as minority or underserved populations, there are veryfew, as you can see, out there. there was one that had about 50% minority and abouta third of dr. vallence's sample was rural. but otherwise there's very limited evidenceregarding randomized control trials for physical

activity behavior change in, for cancer survivorsfrom minority or underserved populations. this is the data from our study in which wedemonstrated the longer-term adherence based on the accelerometer. and what we found wasthat immediately post-intervention there was a significant improvement in minutes of atleast moderate intensity activity per week of accelerometer which was maintained 3 monthslater. this is the data from dr. jones' study in which he compared the usual carewith physician recommendation only versus physician recommendation plus referral. andwhat they found was that the physician recommendation only resulted in the significant improvementin the physical activity whereas when you added the recommendation to the referral,they did not get the same benefits. from the

standpoint of the nccn guidelines and makingrecommendations for referrals to patients it's, it would be interesting to know ifthere's a way to re-frame a referral, or frame referrals so that, you know, it'spossible that patients who were given a referral thought they couldn't exercise unless theyhad the referral or they could've used it as an excuse and in this particular studyby dr. jones, they weren't referred for any specific comorbidity, they were just randomlyreferred. so it might be interesting to pay attention to the framing of the message regardingreferral. this is the other, another study with, demonstratingthe integration within clinical care and this is a study in which dr. pinto combined telephonecounselling with a physician recommendation.

she reported the odds ratio from meeting physicalactivity recommendations for the intervention group compared to the control group and theodds ratio was significant at 3 months and 6 months, but not at 12 months. if you lookat these 11 trials and compare them as to treatment status, whether they reported adverseevents, and whether they excluded individuals based on a medical comorbidity and we seethat all of these 11 were done post-primary treatment. only 2 had reported adverse eventdetails or at least any information about adverse events. and all of them, all exceptone specified medical comorbidity exclusion. don�t get me wrong, i'm not saying thatyou shouldn't exclude because it's primarily for safety reasons. most of the studies werepriority if a patient had a medical clearance

or they would say they couldn't have a significantcomorbidity or they had to able to ambulate or other general terms. some of them wouldactually exclude based on a specific comorbidity. i think this is important for safety purposes,but may reduce the generalizability of these results. so some of the higher risk stratain the nccn guidelines. in any of the studies that mentioned or described the comorbidity,comorbidities within their sample usually would provide only a mean number of comorbiditiesfor the sample. dr. vallence in his study did report the specific prevalence of hypertensionand diabetes. so i pulled prevalence of the conditions from 2 population-based studiesin mixed cancer types to compare the prevalence that was in dr. vallence's study with thosejust to get an idea about how generalizable

the breast cancer, the behavior change studiesin breast cancer survivors might be to individuals with multiple comorbidities. and althoughthe prevalence of overweight or obese was similar to this population-based study, theprevalence of hypertension and diabetes was lower. if you look at the physical activity behaviorchange trials from the standpoint of whether they measured a medical comorbidity relatedoutcome as a secondary outcome, obviously these are behavior change studies so the primaryoutcome is changing behavior. but looking at, i looked to see if they had measured secondaryoutcomes and several of them had primarily body composition related outcomes. we'vemeasured joint dysfunction and inflammation

in our studies as well. it appears that atthe, changes in body weight and composition in these behavior change studies have beenminimal to, minimal or it's small, it's not significant. possible reasons for thismay be the study duration, also the physical activity amount and intensity may not be sufficientto see these significant changes. this is some pilot work that we did with the beat+ resistance study in which we did see a decline in the il-6, the il-10, our pro to anti-inflammatoryratio for the intervention group compared to the control group. this is not specificallysignificant. we were not powered to see that difference, but the pattern suggests thatit may be possible for physical activity behavior change interventions to address some of theshared risk factors between cancer and concomitant

chronic disease conditions. in our beat cancer pilot we also measuredlower extremity joint dysfunction with the womac. in this study we saw maintenance offunction in the intervention group with the control group having a significant increasein the dysfunction. suggesting that it is possible for these behavior change interventionsto manage concomitant chronic disease. so i pulled the 9 that showed significant increasesin physical activity short-term and looked at the, and i've listed on this slide thetheory that was used for development of that intervention and i've underlined the interventionsthat demonstrated or at least showed promise for longer-term increase in physical activityand as you can see the 3 major theories used

were transtheoretical model, social cognitivetheory, and the theory of planned behavior. and i think that those are reasonable theoriesand going forward those seem like theories to continue to be used as we develop and refinethe interventions. we do have 5 studies that have reported mediators or predictors of theintervention effects. and these mediators or predictors have included perceived behavioralcontrol, planning and intention which are part of the theory of planned behavior, alsoself-efficacy, reduced barriers interference, and social support are showing promise aswell. because we demonstrated significant mediation of our intervention effects, wetaught significant mediation by perceived barriers interference. so i wanted to showthis slide which is published data that we

have from over 400 rural breast cancer survivorsand this is the percent who were reporting these barriers to physical activity. as youcan see there are some of these barriers that may overlap with concomitant chronic conditionssuch as fatigue, pain, and fear of injury. i want to mention briefly about disseminationimplementation because it's important that we take what we know about physical activitybehavior change and try to disseminate it to as large a population as we can. we havevery few trials in this area. this is a dissemination implementation trial of the moving forwardintervention that was developed by dr. pinto. this is not a randomized control trial, buti wanted to point it out because it's an excellent example of this kind of work thatneeds to be done. she did train lay volunteers

to deliver the telephone counselling and sawsignificant improvement in the self-reported weekly minutes of physical activity at 12weeks, with some tapering off at 24 weeks. none of the studies have done a cost effectivenessanalysis. it's very important that this be done in the future. this is a, this isa comparison of just, you know, my assessment of the relative costs of these various, thesevarious interventions and then whether the intervention resulted in the short-term increaseor the longer-term increase of physical activity. fortunately, the most expensive one did tend,at least in the pilot study to show some promise. i think what we really need to know is whoneeds the more intensive interventions and who doesn't so that we can allocate ourresources in addition to, obviously, doing

cost effectiveness analysis. i'm sure thereare more than, there are many ongoing trials out there, or there may be some that i'munaware of. i did find these design papers when i did the literature review. the firstone is this study where we're taking our beat cancer intervention and testing it in3 sites. we're enrolling over 200 breast cancer survivors. i think the noteworthy relevantaspect or the noteworthy aspect relevant to this topic this afternoon is that we hopefullywill be able to analyze mediators and moderators of the intervention effect. we are collectingadditional detail related to adverse events and we'll be able to look at study sitedifferences. there's a move more for life study that's being done in australia andit's comparing tailored print versus targeted

print versus standard recommendation. andthey, in their materials include some motivation for resistance training so it'll be interestingto see what they find. then there's a group in spain who's using telemedicine as a wayto encourage physical activity. so i thought that was noteworthy as well. so, in summary physical activity after breastcancer diagnosis can reduce breast cancer risk, can manage coexistent chronic medicalconditions, can improve shared risk factors, can be potentially motivated by the teachablemoment of a cancer diagnosis. we have several effective strategies currently. we certainlyhave, we certainly can improve in this area, but we do have some effective strategies rightnow and they include physician recommendation,

telephone counselling, the pedometer witha step calendar, the in person approach combining individual with group support, and our emailwith access to the e-counselor. i think some future directions related to optimizing theteachable moment, first with regard to considering the coexistent chronic diseases. i think onedirection is considering interventions for breast cancer survivors with significant comorbiditieswho might not necessarily meet the inclusion criteria for some of these other studies thathave been done. i think we need to improve reporting of our adverse events so that wecan design interventions for going forward for individuals who may develop these eventsduring an intervention. and so if we can develop ways to help them deal with that we can improvetheir activity level as well. and we need

to consider a secondary outcome, comorbidityrelated outcomes. i think we need to expand availability through dissemination and implementationapplication in research. we need additional cost effectiveness analysis. we need to thinkabout how we can integrate interventions into the clinical care infrastructure and to continueto work on interventions for minority and underserved breast cancer populations. as far as improving behavior change interventionsfor breast cancer survivors, some areas include further mediator and moderator analysis sowe can determine the active agents within the intervention so that we can maximize theuse of those in future interventions. we need to be examining the moderator analysis todetermine who is going to respond to an intervention,

who isn't, and how can we tailor futureinterventions to these individuals? we also need to focus on longer-term adherence andhow we can achieve that as well as how can we achieve adherence to resistance trainingrecommendations. it's also apparent that we need some during breast cancer treatmentbehavior change trials and there's always a role for continuing to consider how technologyfits within our behavior change efforts. and thank you with that i will wrap it upand take questions. [wendy nilsen] so, please you have an optionfor questions here. you can reach us on twitter at #nihadherence. you can also email me, wendynilsen, at nilsenwj@od.nih.gov it is on the left side of your screen. all of those connectionsso let's hear your questions. i have a question.

i'll start with me because i'm here. howearly do you think in treatment you can start activity? [dr. rogers] i think you can start immediately.you might have to do light activity, a very short duration that's spread out duringthe day or spread out during the week, but you can start immediately just moving aroundas much as you can. [wendy nilsen] great, and do you think, isthis a testable? can we test when we can do it and how much? [dr. rogers] it is testable and there areindividuals who are doing exercise efficacy studies in the 'during treatment' timeperiod. and they're finding it safe to do,

you know, supervised, you know, prescribinga specific amount of exercise at a specific intensity and having them come in and exerciseand they're finding that that's safe. [wendy nilsen] great, and we have a questionfrom one of our listeners and it is "how did spain use telemedicine as an intervention?" [dr. rogers] we're moving back through theslides. so they, they used video conferencing as a way to deliver some of the counselling.and i would have to look up, i cant remember if they were doing the personalized trainingsessions over it as well. i think they may have been trying to do some of that over thetelemedicine as well. if that person lets me know, i'll send them the citation.

[wendy nilsen] okay, we will, for that person'squestions we will send around the citations. so, other questions? do we have any comingin on twitter? they're all a very quiet bunch today. we have a question in the room. [male voice] with an eye towards disseminiation,and evidence showing benefit of exercise as less than productivity guidelines, is therea kind of minimum level that you think would be, maybe not desirable, but kind of whereshould the bar set in terms of what the clinical potency should be for an intervention? [dr. rogers] i usually recommend at leastan hour a week and that's based on, wendy can i go backwards?

[wendy nilsen] sure. [dr. rogers] all the way. i usually base thaton this, that they should get at least an hour a week. and i use this to tell, to tellpatients that, you know, you don't have to run a half marathon, you know. and if allyou can do is an hour a week, you know, do an hour a week. don�t let it discourageyou or keep you from doing it if you cant do, you know, 150 minutes a week. [wendy nilsen] and we're looking at theslide for post-diagnosis exercise and breast cancer mortality. which is saying somethingis better than nothing. [dr. rogers] yes.

[wendy nilsen] other questions? i'm notseeing anything on twitter. sorry, we've got another question here. "in what waysmight electronic clinician-supported electronic tools support positive mediating or moderatingfactors?" [dr. rogers] got a lot of clauses in thatone. [wendy nilsen] i think they're wonderingwhat about electronic technology with support from clinicians might help. how do you thinkthat might affect what you're talking about here. [dr. rogers] well, with more and more practiceplans putting in place what they call a portal where patients can email directly with theirdoctors and they can also do some things directly

online with their ehr, i think that's goingto be a natural, natural evolving next step that would allow clinicians to interact withtheir patients through that portal. i was intrigued by that intervention that used theaccess to the e-counselor through email. i'm not sure, it could potentially be a physicianas the e-counselor, but it also could be a, you know, you know, an exercise trainer orit could be a nurse or it could be someone else on the health care team with the physicianjust as a backup. [wendy nilsen] i think that leads perfectlyinto our next question "could you talk a little about the advantages and disadvantagesof integrating physical activity interventions for survivors into clinical care as opposedto having them purely adjunct treatment?"

[dr. rogers] probably the biggest challengeto integrating it into clinical care is that physicians are so busy that it's, one ofthe challenges is getting physicians to remember to talk about it with their patients and thengiving them the tools to be able to provide them with effective counseling. if you takeit, then the alternative to that is to say okay the physician can have individuals withinhis office who can counsel with patients as part of that, but then there's the issueof cost and how do you pay for that. and to this point, unless it's a nurse which iswhy i was intrigued by the korea study. a nurse can bill for a nurse visit, but if theymeet with a trainer it's not a billable service and so the challenge is if you putit into clinical care, you've got to pay

for it somehow. patients respond well to the,patients seem to respond well to a physician telling them that they need to do it, buthow we fully integrate is going to be a challenge. which i think is why cost effectiveness analysisis going to be important. [wendy nilsen] good, and that kind of leadsright into our next question, which is "what other professionals should we be partneringwith here? pt, occupational? i mean you�ve talked a lot about physicians but are thereother people you think we should be, in medical practices that we should be working with?" [dr. rogers] well, yes. that's a great questionthere, i mean, this tended to focus a little bit on oncology, but there are also otherphysicians outside oncology like primary care

physicians who we would need to partner with.as far as other individuals within the clinical infrastructure, nurses, we should be workingwith them. dieticians who often times can bill for time depending on the comorbidity.they can deliver some exercise counseling as well. let's see. certainly physical therapyis an excellent suggestion because they can bill as well. [wendy nilsen] okay, great. and we have acouple of people that are interested in the technology. i guess that's not surprising.there was a question about what kind of accelerometer was used for the beat study and they asked"was it an fda approved medical device?" [dr. rogers] well it was actigraph.

[wendy nilsen] which is not an fda approvedmedical device because it's a wellness device, so, right. so an accelerometer does not needto be fda approved unless it is addressing a medical condition. but for that questionit was an actigraph? [wendy nilsen] okay, and then there's somequestions about any thoughts on the role, i think you talked about this with clinicians,but on the role of mhealth and encouraging and extending physical activity so mobiletechnology to encourage and extend the effects that you're seeing here, the powerful effectyou have here. [dr. rogers] can you ask the question onemore time? because it's a great question and i want to think about my answer.

[wendy nilsen] okay, the question is "doyou have any thought, given all of this really important work you've presented, what aboutthe role of mobile technology, real time measurement intervention, in encouraging and extendingphysical activity adherence?" [dr. rogers] yeah, i think there are a coupleof things we can do. one of the things that, wendy, you and i were talking about a littlebit ago was that telephone counselling algorithms can be turned into computer generated, youknow, programs where people could call and they wouldn't, maybe not get a real person,but they would get, you know, the computer could interact with them using these algorithmsand it's a way to potentially take some of the telephone counselling and get it outto more people. as far as the, certainly things

like the lifestyle groups, you can deliverinformation over mobile technology and now we have a way for people to interact witheach other so there ought to be a way in which we could harness that as well to try to createthat group, that group effect. [wendy nilsen] and you already used the actigraph,so you're using some of the technology to be able to do real-time measurement. [dr. rogers] well, that's an excellent point.things like this, you know, there are a lot of devices out there for people to wear thatmeasures how much they're moving and how many calories they're burning and what they'reeating and all that. so somehow connecting that into the feedback to the counseling hub,if you want to call it, would really help.

[wendy nilsen] and then there's, switchinggears slightly, "can you speculate about the underlying mechanisms that underlie thebenefits that you've been talking about here? of exercise in survivors." [dr. rogers] the mechanisms of the benefits,not the mechanisms of the interventions? [wendy nilsen] nope. [dr. rogers] okay. [wendy nilsen] of the benefits. [dr. rogers] so the mechanisms of the benefitsmay relate to inflammation. there may be hormonal changes that occur. there's also the connectionbetween more physical activity may help individuals

avoid obesity which can also reduce theirrisk. [wendy nilsen] alright, any other questionshere? we've had some really great questions here. i think this was obviously a fabulouspresentation and it's such an important topic. i know we all think of physical activityin multiple settings, but to think about it's importance in survivors, that might not beso obvious to many of us. so if i'm not seeing any more questions i think we'regoing to be able to, i think we'll have an opportunity to end a little early. fromthe nih i would really like to say thank you to dr. rogers. it's been an amazing presentation.i know we've all learned so much. and we thank all of you for joining us. it's greathaving everybody out there on the line for

us, with us and learning together. so withthat. [dr. rogers] thanks everybody! [wendy nilsen] and we'll talk to you atour next webinar.