Dr. Kerri Winters-Stone, an exercise scientist and Professor in the School of Nursing at the Oregon Health & Science University (OHSU), is the Co-Director of the OHSU Knight Cancer Institute’s Community Partnership Program and Co-Leader of the OHSU Knight Cancer Institute’s Cancer Prevention and Control Program. She is keenly interested in how physical activity can help us prevent and manage chronic diseases and specifically cancer.
Prostatepedia spoke with her about a clinical trial she’s running in conjunction with Movember that looks at how to deliver physical and nutrition advice to men with prostate cancer using digital technology.
How did you come to study physical activity in cancer survivors? What path led you to where you are now?
Dr. Winters-Stone: I’m trained as an exercise scientist with a focus in skeletal physiology, so my original research was aimed at figuring out how we use exercise as a way to prevent osteoporosis and osteoporosis-related fractures in later life, around primary prevention. My research had little to do with cancer, and then I ended up collaborating with an oncology nurse scientist who was a cancer survivor and also a researcher. She was interested in using exercise for cancer symptom management, around acute symptoms when people were undergoing treatment, but at the time, research was identifying more of the long-term late effects of many cancer treatments, such as bone fractures.
In particular, we focused on breast and prostate cancer, and as men and women were being studied for longer periods of time, there was an increasing recognition that bone fractures were now among the many side effects that those cancer patients may experience. So this investigator and I ended up collaborating together because I brought my expertise in osteoporosis prevention into the cancer setting.
We were able, at first, to take the exercise programs and prescriptions that we knew were effective at preventing osteoporosis-related fractures in the general population, which is mainly in women, and see whether or not they would be as effective in preventing fractures associated with cancer treatment.
Interesting. Usually you hear a mentor bringing someone in, but not a colleague.
Dr. Winters-Stone: She became a mentor. I was completely new to cancer, so she taught me a lot.
Why is it important for prostate cancer patients or survivors to think about diet and exercise?
Dr. Winters-Stone: Diet and exercise are important for everybody, right? The new physical activity guidelines for all Americas were released today. They highlight the importance of physical activity for chronic disease prevention, including cancers but also as chronic disease management. One of the things that makes exercise particularly compelling for people with cancer is its ability to help manage adverse effects of not just the illness but also the treatments that accompany the illness. Over the last twenty years, we’ve learned the ways that staying active and moving can help prevent some of the acute symptoms, the GI distress, the fatigue, and the sleep problems that people get when they go through treatment.
Exercise is wonderful because it affects both physical and mental health. It can also help address some of the mental health changes that happen when someone gets a cancer diagnosis, by reducing anxiety and depression. It can be helpful in the short term, so that’s just helping you cope with treatment.
People also tend to decondition over a treatment period, so even if they’re not regularly exercising, they become even more inactive and sedentary. That impacts their day-to-day functioning. When someone is trying to recover from illness, now they’re more detrained from their day-to day-life, and it can be hard to do things like go back to being independent, taking care of yourself, going back to work, and taking care of children. Regular activity can help buffer the deconditioning that happens with treatment.
There’s more and more exciting evidence that suggests that exercise may even play a role in changing the course of the disease. There may be a good reason to view regular physical activity in terms of adding another component to a person’s long-term care. This is something that patients can do for themselves in terms of their prognosis. They can stay active and manage their weight.
Dr. Winters-Stone: There are many reasons. Everybody should do it. It’s particularly important for people who are going through a chronic illness. In the case of cancer, people are usually older and experiencing some declines due to aging, so there’s yet another reason to exercise.
Can you tell us about the trial that you’re running in partnership with Movember?
Dr. Winters-Stone: This is a project that came about as part of an initiative from Movember that was aimed to develop novel and scalable approaches to addressing the problems that men face the most in survivorship.
One of those identified problems was around maintaining a healthful lifestyle. We already know, from well-controlled trials, that a healthy diet, managing weight, and getting enough exercise has benefits for men with prostate cancer, but we’ve not been effective at translating that information into action.
The number of men who still report unhealthy diets and low levels of physical activity remains high even though this information is available. There’s an implementation problem or a dissemination problem. We’re either not getting the information out there, or men are getting the information, but they don’t know how to act on it.
Part of this initiative for Movember seeks to ensure that interventions are scalable to as many men as possible so that access isn’t as much of an issue. Movember required that any interventions or programs be deliverable online or through technology.
In addition to our exercise expertise, we’ve teamed up with my colleagues at University of California, San Francisco (UCSF), who are experts in diet and prostate cancer progression, to develop a web-based diet and exercise intervention program. There are a lot more eHealth and mHealth types of interventions that give everyone a Fitbit and expect people to completely overhaul their lifestyle. But we still don’t know what are the magic ingredients that will translate information into action and change.
Besides developing a way to deliver that information online so it can get to any man anywhere, as part of the study design, we wanted to know how much and what kind of information and support men need for this program to be effective.
There are levels of intervention components that are part of the study design. They go from a low dose and low touch, which provides readable information on the internet, to increasing levels of interactivity.
The next level is to customize a diet and exercise plan for each man. We’re not just going to tell you to go get active; we’re going to tell you what to do with actionable information that’s going to be based on what you tell us about yourself. In effect, we digitize an exercise and diet planner for you.
In case that may not be enough, the next level adds low-cost tech-based motivational tools, like text messaging and a Fitbit, which don’t necessarily require a live professional, but which may add the motivation that someone needs.
Some may need some human contact to put this all in context, so the fourth level includes all of what I’ve said before plus access to a health coach. They get a phone call, a consult, and ongoing advice. We’re trying to understand how effective these different approaches are at improving men’s physical activity levels and dietary habits, with an eye for scalability. You want the most scalable, low-cost yet effective combination. Once Movember gets the results of all of these different interventions that are applied for different outcomes, they will have a web-based suite of support tools and services for men with prostate cancer.
Are you enrolling already?
Dr. Winters-Stone: This trial aimed to enroll 200 participants, and we have enrolled 206. We’re currently following all of these men. They get exposure to the website, whatever level of support they’ve been assigned to, for three months, and we assess them before they get into the website, after three months, and then again three months later.
At that point, will you be reporting out?
Dr. Winters-Stone: Yes. We should have the last man exited with his six-month follow-up in March of 2019.
Right now we can’t yet report on any study results, but we should have an article on the study published in late 2019. But already we’ve heard a few men say, “this has been so helpful,” or “I’ve lost three pounds already.” It’s nice to see at least some individual success stories.
Are there other similar trials that you’ll be running?
Dr. Winters-Stone: This is the only trial that I’m involved with that is completely online, which is more of a distance-based approach than what we usually do. We run a lot of supervised exercise trials, where men come to a facility to exercise, but we also know that not all men may be able to participate in supervised group exercise programs so finding ways to get information out to men regardless of their access to professionals or facilities is important.
Right. Are all of the participants close by, or because it’s web-based, does it matter where they’re located?
Dr. Winters-Stone: They’re all over the country. We have three recruitment sites.
At Oregon Health & Science University (OHSU), we’ve used a hospital registry, so because we’re a tertiary care center, we get guys from all over the state and some neighboring states. We’re trying to capture some of the men who live in more rural locations because that’s typical of our Oregon population.
UCSF recruited through a large epidemiologic study that they have been running, so we have men through who live all across the country. Because their outreach is across the United States, hopefully we’ll get better socioeconomic and racial representation.
And then UC Denver is the other participating site, so we’ve got a lot of men around Colorado. They’re trying to enroll more Latino men because those individuals are in their demographic and we need to ensure that our program can work for men with prostate cancer regardless of race/ethnicity or geography.
Any comments for men about the trial that you’re running or about the idea of this remote monitoring of patients in terms of exercise and diet?
Dr. Winters-Stone: The charge is on the medical and fitness communities to make sure that when men get diagnosed with prostate cancer, they get a recommendation to aim for a healthy lifestyle. There’s probably not an audience member of yours who doesn’t think he should exercise, but he may not know what to do and have trouble getting started.
Well, there’s thinking you should do it and then actually doing it.
Dr. Winters-Stone: Yes, and I’ve heard from so many men that motivation is the barrier. They are knowledgeable, and they know exercise is something that they should do, but they struggle to find the mental and physical motivation to do it. That could be because a lot of the men who I talk to have advanced cancer, and their treatments are just very fatiguing.
So my advice is—and this is out in the new physical activity recommendations—that something is better than nothing. To start, sit less and move more. That is the first step in behavior change.
Even though we have targets and recommendations, the first step is small, especially if that’s where someone is, simply dealing with getting off the couch. Interjecting short periods of standing or some movement for short periods of time would be a good first goal.
The next thing I would say is figure out what motivates you, and enlist that tool. It may be a buddy. It may be your wife or partner. It may be being accountable to somebody. It may be writing down your goals or writing down what you eat. That tends to be very effective.
I’ve known a lot of people who have signed up for My Fitness Pal and lose weight because they had to write things down. Apple Watches and Fitbits can be good in the short term to get someone moving more. Trying to figure out the one thing that might help get you motivated and then taking some action on that.
That’s actually great advice because often we don’t know what motivates us and what doesn’t. You can choose to include that in your life or not, right?
Dr. Winters-Stone: Yes, you can avoid it. It’s like it doesn’t happen, but once you start writing down what you eat, all of a sudden, you have to face the fact that you snack a lot.
Dr. Winters-Stone: Another thing that we have found can be helpful is to try not to go it alone. Loved ones are often asking what they can do to help someone diagnosed with cancer. Maybe they can go for a walk with you.
It’s a positive thing they can do.
Dr. Winters-Stone: It’s good for everybody, and it gives people the time and space to breathe, think about something else, and have good conversation. So maybe that’s the message to give caregivers, friends and family. Instead of asking what you can do, ask to go for a walk.
Then you get the exercise and the socialization too.
Dr. Winters-Stone: Yes. There’s a video a good friend of mine just showed me called Phil’s Camino. It’s about a man with cancer who used walking as his therapy and as his way to come to terms with his cancer. I highly recommend it.