Breast Cancer News

so thank you for coming you guys. just togive you a bit of a background on myself in terms of where i came from with this areaof research. my background in training has always been in exercise science and firstof all, physiology then exercise psychology. so i have dual degrees in psych and in kinesiology.and when i was doing my ph.d., i had the opportunity of working with dr. don mckenzie who is anindividual who kind of started the movement for dragon boating for breast cancer survivors.and in his capacity, he was interested in physiology and dispel the myth that peopleshould not, women should not exercise after having mastectomy in the event that they mightdevelop lymphedema. so his choice was dragon boating because it was an upper body strengthbased activity to sort of dispel this myth.

he is a physician as well. so i'm workingwith him, you know my interest was in the psychology aspect of it while he was doingthe physiology stuff. and so that really was my interest in breast cancer and cancer ingeneral. and after moving from vancouver, where i did my ph.d. to montreal, it was morea matter of what the women were getting from in dragon boating that we could develop intoother interventions because not everybody either wants dragon boating or has accessto water and the dragon boats that exist. so we want to be able to give them the most,the best possible intervention. so with that in mind, you know sort of maybe along theway, i'll give you my pet peeve in this whole area. you know this is an area that has aton of research; we know there's a lot of

interventions out there. we know bringingpeople into a gym, having exercise is beneficial and moving on from all that research, whati feel is we've jumped too fast into the intervention research without fully understanding the contextof physical activity and how to get more people active. because canadians aren't active enough,cancer survivors aren't active enough, cancer patients aren't active enough so i think we'veyou know kind of jumped too far into bringing them into a gym, 5 days a week for 30 minkind of routine. because even though it's beneficial short term, when people leave thegym atmosphere, they don't go back to exercising. so that's really the context of what i'm goingto talk to you today about. most of you are probably aware of a lot ofthese early slides that i've put in here.

but really just to highlight the fact thatonce individuals are diagnosed with cancer, they are more susceptible to mental healthproblems including depressive symptoms, stress, anxiety, one of my other areas of interestis in body image. as well as the physical health co-morbidities including the ones upthere- so fatigue, pain, immune function challenges, biological functioning which is often studiedusing cortisol or stress, measures and variety of health conditions. so once someone is diagnosedwith cancer and in particular i focus on breast cancer, the survivorship rates are quite highbut the co-morbidities associated with having had cancer are also quite high. and so weneed to identify these modifiable factors that we can intervene and help these individualsbecome healthier and reduce their risk for

these comorbidities. so of course my interest is in exercise andthis is one of the areas where physical activity is probably one of the strongest known non-pharmacologicalinterventions that we can give to individuals after cancer to help reduce the risk of co-morbiditiesas well as improve their survivorship experience. so for those of you who aren't familiar withphysical activity guidelines, now we do have guidelines. these were first published in2010 and now there's been a number of other guidelines published around different cancersurvivor groups or cancer groups. generally speaking, the guidelines suggests to avoidinactivity so promoting physical activity, individuals should be active as much as theycan be basically, it's feasible, it's safe,

it's effective to be physically active andthe guideline suggests cancer survivors should engage in 150 minutes of moderate to vigorousactivity per week plus 2-3 days of muscle strengthening activities and flexibility exerciseson the days when they do any of the other exercises. so really for those of you notfamiliar with general canadian physical activity guidelines or american guidelines, these areexactly the same. so the guidelines are no different for survivors of cancer if as theyare for the general adult population. we should be engaging in this level of physical activity. so in a lot of work that we do, we often lookat what role physical activity plays in a variety of context across what we call thesurvivorship trajectory, whatever you want

to call it or the continuum ranging from pre-diagnosisall the through to end-of-life. physical activity can play a role in this pre-diagnosis, it'sreally focused on prevention. and there's strong strong evidence showing that physicalactivity is preventative facet of one's life style to help prevent from a variety of cancersincluding breast, colorectal and prostate cancer. when we get into and independent ofthe naming that i put here, this is just based on some research that suggests that there'sdifferent phases of survivorship but regardless of this, in the early stage of being diagnosedwith cancer, physical activity really plays a role in physical functioning. so we wantpeople to be able to get to their treatments to be able to sustain some sort of qualityduring the time of treatment and the quality

of life really factors around physical functioning.being able to maintain strength, maintain agility, ability to move around, and get totheir treatments. following that, you know during this sort of what i call the end oftreatment phase, early end of treatment phase for individuals it's really focused on qualityof life and physical activity can help individuals increase physical health, increase mentalhealth as well as social well-being. a lot of activities focus on group atmosphere, groupactivities, dragon boating is a good example of that. and there's some literature to suggestthat physical activity helps spirituality. if you can think of things like yoga in particularare highly driven towards them, that nature or quality of life. this idea of permanentsurvivorship, again whatever we call it, it's

sort of the longer-term survivorship period,you know one year post-treatment and beyond. and really the focus of physical activityat this point is to reduce co-morbidities. individuals who have gone through cancer treatmentare at higher risk for cardiovascular disease, osteoporosis, depression for example, diabetes,hypertension so all of these co-morbidities can be sustained with physical activity aswell as secondary cancers. and then of course in that post, end-of-life period, we findthat physical activity plays a role in coping with more generally that pain. so there'sa range of roles that physical activity plays across the cancer continuum really. so just to focus a bit on the pre-diagnosis,this is again where the area has quite strong

evidence of physical activity. you can seehere on this slide just showing you the different types of cancer and percentage of studiesthat show that physical activity reduces cancer risk. so you can see here 76% of the studyfor colon cancer shows that there is some sort of risk reduction as well as a dose-responseeffect so what i mean there is the more activity that's done, the more risk is reduced in thatcontext. so you can see along the way, the percentage of studies that show there is apreventive aspect to physical activity and it is quite strong overall for the majorityof cancers. okay so then we talk about what are the benefitsto being diagnosed with cancer and basically the benefits are far reaching.

so i have a slide up here if you can readit on all of the different benefits that have been shown in a variety of different papers.so you can see anything from actually reducing rates of deaths so survival rates have improved,immune function, cardiorespiratory fitness, flexibility, muscle strength, all of thosethings down to body image. so you can see there physical activity targets all areasof the body in terms of benefits to this population. and like i just mentioned, risk of recurrenceand improved survival. so one study, this is the heal study in the states shows that2-3 hours of walking per week after diagnosis improved survival in a breast cancer populationand in a colon cancer, pre-diagnosis physical activity was not related with reduced riskof recurrence but post-diagnosis was. and

this really speaks to there's been quite afew studies looking at what's the best time to start physical activity if you've neverbeen active in your life and you're diagnosed with cancer. if you start now, does it matteror should have you been active your whole life. and what we find is starting any timeis better than not starting at all. and much of the evidence shows that lifetime physicalactivity, while it reduces the risk of having cancer once cancer has been diagnosed, anylevel of physical activity after that is highly beneficial. so here we just show that physicalactivity again in general, like i mentioned in my introduction that people are not physicallyactive. and when we take in particular breast cancer or women so women are less active thanmen regardless of who we're talking about.

older adults are less active than youngeradults so when you think about cancer and breast cancer, women tend to be diagnosed,the average age is between 55 and 60. so you're talking about an older age female populationthat's in the least active category already. so estimates are about 5-10 minutes less activethan healthy or women without cancer. and the evidence shows up to 80% of these womenare not active enough. and this is predominantly with self-report measures. we know, and ithink i have a slide on that slide, that self-report may be biased- people tend to say they domore than they actually do. so if we think that self-report estimates 87% of people areinactive, we can imagine what they actually really are. one study using a national basedstudy, a population-based study showed that

breast cancer survivors spent 1.1% of theirdays active. and that equates into about 4 minutes per day. and that was with measuredphysical activity levels. so when we use accelerometres.... ...which i'll talk about in a second. so thisslide just shows you the percentage of indivdiuals meeting guidelines at 150 minutes that i putup early in a range of different cancer types. you can see here the bottom line is that pre-diagnosislevels are and this is self-report, pre-diagnosis levels are around 30%, 20%, during treatmentsthose rates go down and they never really come back post-treatment to what they werebefore and before rates were low to begin with. so when i just talked about self-report versusobjective measures you know we use a variety

of measures in terms of physical activity.self-report measures are very good at measuring the type of activity people do because youcan write it or there's a list that asks them what they've done. it's very good at gettingat amount because if you can direct people enough, they can have an estimate at the amountof physical activity and they can usually say what level of intensity they're exercisingat. the problem with self-report is of course the social desirability like i mentioned aswell as the fact that when you're measuring physical activity on that questionnaire, it'spurposeful. so you think back 'okay when did i put my running shoes and exercise or whendid i go to the gym?' and it's really only those bouts when you actually made an effortto be active. whereas accelerometer and i've

put a couple of pictures there for you aremeasuring activity all throughout the activity. so unpurposeful bouts, whatever you're doing,it's being measured. so you could argue that one, neither is better or worse than the other-it depends on what you're actually looking at. if you want to know truly how active someoneis, how much energy they're expending per day, then an accelerometer works very well.but if we're trying to change behaviour, then we probably want to target the behaviour thatpeople know what they're doing which is the self-report. so a lot of the articles nowhighlight the fact that when you measure physical activity, you need to use accelerometers butthere is a pretty big downside to that. it's you get a lot of noise in that measure andso in particular, when we're trying to target

higher intensity activity, the accelerometersare measuring everything and it's kind of being all clumped together. however, thereare benefits to that in that it is an objective measure so it's not driven by this socialdesirability. and then just to highlight the other aspectof the field now so one push is to use accelerometers to better estimate physical activity. theother is sedentary behavior. so up to a few years ago really, sedentary behavior was operationalizedas a lower level physical activity. so if you're not active, you're sedentary so it'sone continuum and you're either sedentary, all the way up to being active. and now thecall is to suggest that sedentary behaviour is its own behavior. so you can have low tohigh levels of sedentary behavior and you

can have low to high levels of physical activity.and they're being operational now as two separate distinct behaviours because if you think aboutit, someone can be quite sedentary throughout the day but also meet guidelines. so if you'rethe type of person that goes for a brisk walk or a run at lunch for half an hour day duringthe week, it would meet physical activity guidelines. but if you sit from the minuteyou wake up til the minute you go to bed other than that half an hour, you're actually verysedentary. so high sedentary, highly active. so that's why they're sort of distinguishingbetween these two behaviours now. and the literature not in an oncology context butgenerally in other general populations have suggested that sedentary behaviour has itsown risk factors, its own outcomes. and now

there's been brigid lynch in australia andcolleagues for this has called for this a new cancer survivorship agenda examining sedentarybehaviour in addition to physical activity. in that one study that she did with populationlevel, individuals with breast cancer, she showed that 9 hours of their day were spentin sedentary pursuits. and if you remember before about 4 minutes of the day were spentin moderate to vigorous activity. so what we don't know yet around sedentary behaviouris you know what are the unique predictors and outcomes in an oncology context as wellas what patterns of sedentary behaviour are there. so some of the literature shows howmany times do you get up and sit down so breaks in sedentary time have their own outcomesversus how long you're actually sitting. so

the distinctions around that and the typeof behaviour we're studying is sort of up in the air in the research world. so a lot of what we do now is or the focusnow is on intervention research. and i would say as i mentioned earlier, the bulk of itis on physical activity. now they're starting to be some interventions on sedentary behaviourso can we create and we're doing some now for example with prostate cancer survivors,looking at can we intervene at sedentary behaviour levels? so if we can't get people to a gym,can we at least get them to be a little bit less sedentary? can we remind them with watchwristbands and emails that say, "stand up, it's been half an hour, can you stand up now",and does that have an impact on quality of

life. so all of this to say in terms of whati'm going to talk about for the big study that we have going on is that little is knownabout sedentary behaviour and also i would argue that we know quite a bit about physicalactivity from an intervention context but we know very little naturally. what happensnaturally to physical activity levels after diagnosis of breast cancer? do they tend togo down? do they tend to go up? is there this teachable moment that we hear about or not?and if it does go up and down, are there times after diagnosis or after treatment when weshould be intervening? and are there times where physical activities are excessivelylow or high for example. so that's really what we're focused on here.

so i'm just going to talk to you today aboutthe natural changes in physical activity and sedentary behaviour among women who have completedtheir treatment for breast cancer. and sometimes i get asked this question around 'why didwe focus on post-treatment?' and to me, during treatment is a very different phase of lifethan post-treatment. the barriers are very different to be physically active when someoneis actively in treatment versus post-treatment when you would expect that it's possible whenyou start helping them develop physical activity and lowering sedentary behaviour routines,that it could be sustained long-term. versus during treatment when things come up, thingsget going, energy levels are different, you have to get to the hospitals for treatmentso that's why we focus on post-treatment period.

and we were also interested in weight statusbecause weight has a lot to do with breast cancer population. 50% of women in this studyare overweight. so we wanted to look at how that impacted physical activity and sedentarybehaviour levels. and also, most people look at bmi but now another area of research isreally focusing on different indicators of body composition. so waist circumference forcentral adiposity or waist to height ratio which is also a measure of central adiposity.so we looked at these two different measures of weight status. so our sample is we have 199 women in ourstudy. this study today i'm showing you, 153 participants that went through for what i'mgoing to talk to you about today. and we have

the mean age is around 55, you can see therethe mean bmi 26 so again 50% of the population is overweight. and the general treatment imean, general descriptive near a lot of the population based studies we have in canadaand north america in terms of types of treatments that they've had. i'll note down that thevery bottom month since treatment is about 3 and a half months. we've tried to catchthe women as soon after treatment as we could but some of them needed just that you know,"i'll start in a month," sort of thing. so the average time was 3 and a half months. so we targeted them at that point, 3-4 monthspost-treatment, they were recruited from physician referral, advertisements in clinics aroundthe area. we had them do self-report questionnaires

5 times- so every 3 months. they also worean accelerometer for a whole week for 7 days every 3 months. they gave us mood questionnaireson 3 days during the week that they wore the accelerometer. and they also gave us salivafor us to look at cortisol, the biological functioning on 3 days during that week andthey gave us a blood sample to look at, immune biomarkers. so all of this was done every3 months for the year post-treatment and then we got follow up funding to look every yearfor the next 5 years. so we have really intensive data for the first year and then every yearthere after we have follow up data on these women. so we use the actigraph accelerometer.i won't get into the details of this but we basically did what we should have done withthe accelerometer data. the one benefit of

using accelerometers is as well is that youcan look at different intensities of physical activities so not only moderate to vigorousbut you can also look at light levels and you can measure sedentary behaviour. it hasan inclinometer function in it so it says whether you're supine or not basically ishow it looks at that. we had weight status so we had a trained labtechnician measure weight, height, waist circumference on the first data collection and after that,the women were taught how to do it and they did their own waist circumference and weightfor every measure after that so they didn't have to come to the lab every time. and thestability estimates were there, they were quite stable in terms of their weight in thatyear.

so this is who are meeting the guidelinesso that 150 minutes of moderate to vigorous activity. you can see measured activity westart off with about 29% to our meeting guideline and drops down to 22% at 12 months. so ifthere you know the title of my slide was sitting on the crest of the teachable moment, i guessmy argument would be if there was such a teachable moment, we either missed it in this data collectionor it doesn't exist because we would expect those numbers to go up not down. so we don'tknow if that baseline post-treatment is sort of the highlight and that they did changetheir behaviours and now it's on the downhill or not. but i would argue again that thisis the timeframe that would be long-lasting lifestyle behaviour. so a little bit discouragingin that regard.

here is just looking again at same sort ofdata but this is percentage of time that they've spent in moderate to vigorous activity. soyou can see 2% of their time at time 1, it goes up well 1.95 goes up to 2 and drops thereafter. and there was a significant linear effect for this variable. so moderate to vigorousactivity, percentage of time spent in it basically decreases over time. the opposite for sedentary behaviour. so youcan see here time 1 about 78% of their time is spent and then it drops down before itgoes up. so obviously the axis the time period here is quite small so you can see it rangesfrom 77.4 up to 77.8. so we're not talking about a huge increase but it is a significantincrease because this is a percentage of time.

it equates to about 10 minutes differencein terms of their sedentary behaviour. so i just want to also highlight that one ofmy interests is really in looking at focusing on light activity. because i feel that orwe know that most individuals don't like moderate to vigorous activity. if you ask people whatthey enjoy and what activities they enjoy doing, it tends to be walking, predominantlyand then you know things like swimming or yoga, pilates those kind of activities- gardening,housework. i don't know who likes housework but those types of activities are really thelight activities not moderate to vigorous. and what i feel that we've done a disservicein the literature, we tend to always not look at the light activities and we tend to alwayshighlight the moderate to vigorous but we

need to better understand the effect of lightactivities to know whether helping people just engage in light- is that okay? can wegain benefit from that? and so that's part of this study that we're also looking at istrying to identify what we can do, what light activity is associated with so we might beable to target that level of activity a little bit differently than we have in the past. so these are just looking at the associationsbetween those different intensities of activity in the study. this is just baseline data soyou really can see the displacement between sedentary and the light and lifestyle. sothey're highly correlated. if they're sedentary then they're reducing their time spent inlight and lifestyle activity, more so than

moderate to vigorous activity. and that'sbasically the bottom line of that slide. and then if you remember the objective wasto also look at weight status. so if you can see here, the blue line are those individualswho are considered overweight based on waist to height ratio. and the grey line are thosewomen who are of healthy weight based on that. and you can see here the general trend forthose people who are overweight just goes up. and again if you were going to targetan intervention or you were to look at this data, then at baseline you really could startwith the individuals who were overweight. healthy weight women in this study, it tendsto be about 6 months before it goes up again. so you know again maybe that's a time frameto look at start intervening with these women.

and if you think back to the graph that wehad. the other group based graph show that about that 6 month time frame is where sedentarybehaviour starts to increase and physical activities really are decreasing. and if iwere to work with physicians at that point, it would be around that timeframe where iwould argue we need to start looking at physical activity. we need to start addressing physicalactivity in clinics to suggest that that's when the information needs to get out there. this is percent time in mvpa so both groupsthey sort of go down. the healthy weight women go up a little bit before it starts droppingand are always more active than the overweight women.

and this is just showing you the light andlifestyle activity just to show you the trends are very similar in that. so around weightstatus, the healthy weight women are always more active and less sedentary than the overweightwomen in this sample. so then i just want to quickly talk a littlebit about the you know so what? we know now that natural changes in physical activitytends to go down, sedentary behaviour tends to go up at 6 month mark tends to be the area/timethat we want to target. but does this all matter? and so really in this study, we'refocused on a number of facets of mental and physical health. and i just want to sharewith you a couple of the findings that we have in this regard. so this was the healthmodel that we're following in this study.

so generally speaking, physical activity andreductions in sedentary behaviour should relate to better mental health. better mental healthwould improve biological functioning that we're operationalizing as cortisol stresslevels and immune function. and with healthy biological functioning, we would expect betterphysical health. so that's what we're looking at. and so today i'm just going to look atgenerally speaking some of the associations between all of these facets. and looking atall of these things, i'm just going to present to you now baseline to time 5. so change overone year in physical activity, what does that relate to in terms of these other facets. so you can see here these are the correlationsbetween change and physical activity on the

left and change in sedentary behaviour overthat first year a the range of different variables that i looked at for the presentation today.so the ones in bold are significant at p value of 0.05 and those in italics if you can seethem are significant at p of 0.10. so what i'll highlight is that physical activity,the first observation that you get is right away physical activity is stronger in relationshipto all of these facets than sedentary behaviour. however, we do see some interesting associationswith sedentary behaviour. in particular, if sedentary behaviour goes up, stress goes down.same thing with physical activity. so the same type of association and i would arguethat sedentary behaviour in an oncology context is going to be complicated to look at becausethese women say that they need that time.

they need to just sit down, it's actuallypart of their coping repertoire. it's actually beneficial to their mental health to be sedentaryin some capacity. so arguing perhaps that is part of the argument in that context. youcan see though that increases in sedentary behaviour are associated with increases incancer worry. and increases in sedentary behaviour are related to increases in sleep quantity.so the more sedentary they are, the more they sleep. and the opposite sort of trends withphysical activity here over time. ptg is post traumatic growth so that was one factor thatwe wanted to look at from a positive aspect. i know there's a lot of controversy in theliterature as to whether post-traumatic growth should be studied or what it actually is.but we did assess it over those 5 time points

and it is related to physical activity. sothe more active women are, the more they experience aspects of growth. and we saw that as wellin some of the dragon boating stuff that we've done as well. and just one more point. hereone of the interesting stuff in our data and this is only with 78 women who gave us fullblood samples for all 5 time points but c-reactive protein is lower in those women who engagein physical activity. and that trend that we see actually is consistent across all 5time points and at within level and between level. so suggesting that generally speaking,we see this type of association between physical activity and decreases in immune, in crp.but we also see it that if a woman is more active than her average, then she has reductionsin crp. so being a little bit more active

than you usually are actually is protectiveof immune function as well as generally being physically active. so that's an interestingfinding that we're grappling with and writing up right now. so just to summarize that, changes in lightand lifestyle physical activity which i didn't put on the previous slide were related todecreases in cancer worry and stress. changes in moderate to vigorous activity were relatedto a bunch of mental health and physical health outcomes. and changes in sedentary behaviourwere related to a little bit less than physical activity overall. and when we tease apartsome of those associations, we also see that link between moderate to vigorous physicalactivity and these outcomes is really driven

by moderate intensity physical activity. veryfew women actually attain vigorous level of physical activity. i think it's 0.01% of theirday is spent in vigorous. so when we even say moderate to vigorous, it's really moderateintensity activity. so we do need to target interventions targeting that moderate to physicalactivity but also based on some of the stuff that we're seeing, light and lifestyle activitydoes have some positive benefits as well. and i would also argue that light and lifestylephysical activity and i put precursor up here because if we can help people start to beactive at that light level, it may in fact translate to moderate to vigorous at somepoint. so there may be a continuum that we need to target light activity first, thereare some benefits, and then push them to be

more actively engaged as time goes on. andyou know that's really following any of the typical behavioural counselling psychologyphysical activity literature. and i already talked about the nature of sedentary behaviourin this oncology context. so this graph is just showing you again whatwhere we need to go with a lot of this literature is the data that i presented was at a grouplevel. so taking all 153 women that we had full sample in this study and looking at meanlevels but it doesn't mean that there aren't women who are increasing and it doesn't meanthat there's women who aren't decreasing a lot. so what we need to do and what we'redoing now is teasing out that data analysis form where we can look at individual physicalactivity level and you can see here, i think

i took 13 participants and i just graphedall 5 time points for you to see the differences over time in those 5. so you could see youknow the teal colour one there really goes up at time 2 and comes way down. you can seesome of the blue ones are up quite high and them come down and then the people at thebottom who sort of stay stable. so what we want to do is identify those women who decreasing,the women who are increasing and the women who are staying the same. and looking at predictorsand outcomes of those women to see what we need to do because it really is in physicalactivity interventions, it's not a one size fits all kind of approach that we need totake. you know if resources weren't limited, we would take that perspective but we needto do the best that we can with what we have.

and so i just talked to you again about thattime period of 6 months where we should probably be intervening. this graph is just what ialso showed you in terms of the data so that time in red is really where we probably shouldbe working with the oncologist and the follow-up appointments with practitioners, whoever thatteam may be to target physical activity at that time frame. i'm not going to talk aboutthe other side there. and this slide is just the american instituteof cancer research putting it out for cancer prevention showing you a typical active dayversus a sedentary day. so you can see the top person kind of gets up, walks everywhere,gets up to get water, you know goes out for a walk at lunch, walks, walks, takes his bikehome and it's quite active and has quite a

low risk for cancer. whereas the bottom personthere and you can see there is basically gets up, sits down, gets in her car, sitting inthat desk, sitting, sitting, gets in her car to go home, sitting, sitting, watching tvat night. so you can see her risk is the highest. so you know we often target and with the researchwe're doing now showing that light activity is beneficial, reducing sedentary behaviouris beneficial, some of this stuff is important. you know it really is about those remindersto stand up more throughout the day and try to help people identify times in their daywhen they can be more active. and just to end this is our new study. actually jenniferjones is a co-investigator with this one me. basically this study was developed to helpmore women become active and so one of the

barriers that we often hear to physical activitylevels is women don't have someone else to exercise with or to call them up or the informationneeded to be active. and because there's not enough trainers in the world to be matchedone-on-one with every single person, we've developed this online what we call, activematch. so i describe it as my lava life for exercise. really it's helping women find amatch to their activity levels and someone else they can exercise with or someone elsethat will call them on the phone and say, "hey, were you physically active today?" sodepending on what their needs are, they'll develop a profile, the profile will be matchedto their top choices and they'll be able to identify that person and go out and exercisewith them or again have them call them on

the phone and see how they're doing. so wewill part of this website will be providing them with information on how to set goalstogether, how to keep people accountable together as well as examples of exercises that theycan do in pairs or in small groups because some of the women say they want to be in groupsof 3 versus than just 2. so we're trying to help people in any way that we can and partof this process might be the value be after you know there's a lot of programs in hospitalsfor people once they're diagnosed with cancer that lasts 12 weeks, provide physical activityas well with a bunch of training. and then they're left on their own. so if we can offerthis kind of service for the post-program time, then maybe we can help more people beactive. right now we're focusing on women

but eventually i've had a lot of emails andcalls about this from men and from women who don't have cancer so you can't appease everybodybut this is a good first start so i just thought i'd put that out there. so i think that's it. i'd just like acknowledgeour funding for the data so far.