Provider Chat with Kathryn Schmitz, PhD, MPH

In this episode of Cancer Survivor MD, Dr. G. van Londen and Brad Buchanan speak with Dr. Kathryn Schmitz, Professor of Medicine at the University of Pittsburgh, Co-Director of the Hillman Cancer Center Survivorship Program, and Founding Director of the Hillman Exercise Oncology Program (Moving Through Cancer).

They discuss how Hillman is integrating personalized exercise into routine cancer care, along with the benefits of strength training for muscle, bone health, lymphedema, neuropathy, and recovery. Dr. Schmitz also shares UPMC’s groundbreaking efforts to make exercise oncology a covered healthcare benefit.

Her central message is simple: exercise does not have to be intense. Start where you are, do what you can, and build from there.

Links pertaining to topics discussed in this episode: 

• UPMC programs: 
  • https://hillman.upmc.com/cancer-care/survivorship-program
  • https://www.movingthroughcancer.com/
• Cross-linking podcast episodes: 
  • Man Up To Cancer: https://www.buzzsprout.com/2308830/episodes/18560768
  • Janette Poppenberg, cancer certified personal trainer: https://www.buzzsprout.com/2308830/episodes/19198724
• Research:
  • Challenge trial at https://pubmed.ncbi.nlm.nih.gov/40450658/
  • Healthy Lifestyle Advice and Practice Among Cancer Survivors in the US at https://jamanetwork.com/journals/jamaoncology/article-abstract/2848247  
• Cancer Programs: 
  • https://www.facs.org/quality-programs/cancer-programs/commission-on-cancer/  
  • https://www.facs.org/quality-programs/cancer-programs/national-accreditation-program-for-breast-centers/ 
  • Living Life Post Cancer Treatment: https://cancerbridges.org/specialized-programs/
  • LIVESTRONG at the YMCA: https://livestrong.org/how-we-help/livestrong-at-the-ymca/
  • https://www.strengthandcourage.net/
• Plyometrics at https://www.hss.edu/health-library/move-better/plyometrics-workouts-for-beginner
• Experts: 
  • https://www.ohsu.edu/people/kerri-winters-stone-phd
  • https://people.wright.edu/karen.wonders
    
    

General Links:

• Disclaimers: https://cancersurvivormd.org/disclaimers/
• Brad Buchanan: https://linktr.ee/bradthechimera
• G [Josie] van Londen: https://linktr.ee/cancersurvivormd
• CancerBridges: https://cancerbridges.org/

Transcript

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Provider Chat with Kathryn Schmitz

[00:00:00] G van Londen (2): Hello, everybody. Welcome to our next episode of Cancer Survivor MD. We're very lucky to have a special guest with us today, Dr. Kathryn Schmitz. I have known Kathryn, I was trying to do the math, but that's a little hard to do. I think it's close to if not over 20 years. Yeah. She's had a very long-standing career in which she makes gradually but steadily progress in making exercise safe, effective, evidence-based, and accessible to cancer survivors, and meet them where they're at in the hospital, in the outpatient setting.

[00:00:46] G van Londen (2): And she has done that in the clinical setting, but also everywhere in between up to the top level of trying to make policy changes that then result in insurance changes. And I'm very, very proud of [00:01:00] her. And I was so sad because it was my dream to be able to work with her. But that didn't work out, because She came to the University of Pittsburgh right around the time that I had to medically retire.

[00:01:17] G van Londen (2): And so right now, Kathryn Schmitz has multiple positions at the University of Pittsburgh. One of them is the Professor of Medicine. The other one is she's a co-director of the Hillman Cancer Survivorship Program.

[00:01:32] G van Londen (2): And another hat she wears is the Founding Director of an exercise oncology program called Moving Through Cancer. She is also the Deputy Director of the Hillman Cancer Center and the Associate Director of Population Science. And before I give a word to Kathryn Schmitz, I should always remind myself that Brad is here with us.

[00:01:58] Kathryn Schmitz: Thank you so much. What a kind [00:02:00] introduction. And Josie, I have such fond memories of, connecting with you when I was a professor at the University of Pennsylvania.

[00:02:08] Kathryn Schmitz: and you know, we were both involved in a process of the development of a CD, that was intended to help breast cancer, survivors to do upper body resistance training at a time when it was verboten. And, and we were, bucking the data because we saw that there was real value, to, having these women be more physically active.

[00:02:30] Kathryn Schmitz: And then, I came out with the results of a very large trial that showed that indeed it was not only safe, but beneficial, for women to do upper body strength training after breast cancer. So, um, so we've been tied together and interested in the same ideas for a very long time. So it's delightful to have an opportunity to sit down and chat with you

[00:02:50] G van Londen: Thank you, Kathryn.

[00:02:53] G van Londen: Brad, would you like to say something or sh- shall I keep going for now?

[00:02:56] Brad Buchanan (2): Um, yeah, I, I am very [00:03:00] delighted to have Dr. Schmitz here, but, I would like to hear more about her work and career and the research before I ask my incredibly intelligent, questions. 

[00:03:10] Kathryn Schmitz: Okay. Thank you, Brad

[00:03:13] Exercise programs for cancer survivors

[00:03:13] G van Londen: Well, uh, where to start? Would you like to talk about your exercise oncology program? Where would you like to start, Kathryn? 

[00:03:21] Kathryn Schmitz: Sure. Why don't we talk about the Hillman Exercise Oncology Program, and, we'll talk about kind of where it came from and why I've designed it the way I've designed it, and what we're hoping, is true based on doing this program.

[00:03:33] Kathryn Schmitz: there are programs that are out there across the United States and beyond, for, cancer patients and survivors, and they're designed in different ways. And, you know, so, the Livestrong program at the YMCA is a wonderful, wonderful program that is, community-based and, that brings cancer survivors together in, in a group, in order to learn how to safely exercise and, [00:04:00] recover from their cancer, treatments.

[00:04:02] Kathryn Schmitz: that's a wonderful model. it's a model that, works really well for the people who are available at the time that session occurs at the YMCA and when it starts. So that program starts, three or four times a year. It's 12 weeks long, and it's offered, say, Tuesdays and Thursdays at 7:00 PM or something along those lines.

[00:04:27] Kathryn Schmitz: So if that happens to work for you and you have that program near you, it's brilliant. And so, that's great, and people who can enjoy that program should. and you know, I'm a huge fan of the Livestrong program. What we were interested in was trying to fill in the gaps for the people who don't either have a Livestrong program near them or for whom, getting to a program at, you know, Tuesdays and Thursdays on a thir- you know, in the evening or whatever the timing ends up being, doesn't work for them.

[00:04:56] Kathryn Schmitz: And so how do you meet the needs of somebody? Because, you know, [00:05:00] that's not how we practice medicine. We don't offer people chemotherapy on Tuesdays and Thursdays at 7:00 PM. we offer it to them according to, appointments that because it's urgent, you know, we wanna make sure that it's gonna happen, on an urgent basis.

[00:05:12] Kathryn Schmitz: and so we see exercise as an urgent issue and, so what we've done is we've developed a triage tool, in collaboration with, some folks that, you know, developed a really long version of it. We made it shorter and easier to implement within the clinic- And, the medical assistants ask the patient these six questions, when they come in for, an infusion visit for chemotherapy or im- immunotherapy.

[00:05:39] Kathryn Schmitz: based on the answers to their questions, a staff person from my team approaches the patient and says, "Hey, it looks like you're having some difficulty climbing stairs. You're having difficulty with numbness in your- and tingling in your feet and your hands," or with fatigue or whatever the issues are that they report on the survey, "and [00:06:00] we can help you with that."

[00:06:01] Kathryn Schmitz: And we then triage them to either, be referred to physical therapy or we develop a home exercise program for them that is specialized to their particular needs, or we refer them to community programs like Livestrong at the Y. And those are-- That's generally for the ones that have less urgent issues.

[00:06:19] Kathryn Schmitz: we find that about half the patients are getting referred to a program like Livestrong. and the other half we're doing some kind of program for them at home or sending them to physical therapy. we've been doing this program at the Shadyside location of Hillman Cancer Center for three years now.

[00:06:35] Kathryn Schmitz: there is also exercise oncology programming available through Hillman at New Castle, as well as at, Erie. the Hamot Foundation has very kindly funded a staff person for the Moving Through Cancer program at the Erie location of Hillman, for the past year. we've seen over 2,000 patients now, doing this program, and we feel like we've learned a lot about, what people are interested in, [00:07:00] what they're not interested in, and what works.

[00:07:02] Kathryn Schmitz: We've, pivoted a number of times in how we're delivering the program so that, if somebody thinks they just wanna kinda do it on their own, then we can give it to them just kind of on their own. If they're like, "Hmm, I think I might need some support," then we can do some telehealth sessions with them if they're interested.

[00:07:20] Kathryn Schmitz: we can do phone counseling if that's of interest. So we try to meet people where they are, including, recognizing Where they are behaviorally, where they are clinically, and where they are in terms of sort of social issues. we recognize that, just because you're dealing with cancer doesn't mean that you don't have a parent with Alzheimer's or, a child that's going through a difficult time.

[00:07:48] Kathryn Schmitz: there can be a number of life issues that are happening. And so what people are really ready and willing to do with exercise during and after their cancer treatment varies a great deal over time. So we're [00:08:00] trying to be very flexible to help them get the best possible function and symptom outcomes from exercise, while at the same time recognizing that it's a complex time going through cancer.

[00:08:12] Men and Exercise Programs

[00:08:12] G van Londen: Thank you, Kathryn. I see Brad turned his camera on. Brad, would you like to ask a question? 

[00:08:18] Brad Buchanan: Uh, sure. Um, so as you can see, uh, or I hope you can see anyway, I'm literally wearing my Man Up to Cancer hat as we speak, which is a reminder to ask the question, to Dr. Schmitz, about gender and exercise and...

[00:08:38] Brad Buchanan: So the reason why Man Up to Cancer exists, it's a support group for men going through cancer. The reason why this group exists is because men don't join other support groups- at the same rate that women do. 

[00:08:52] Kathryn Schmitz: Yes. 

[00:08:52] Brad Buchanan: And so I'm wondering if that is also true for your exercise programs. And if that is the case, then what, if [00:09:00] any, steps can be made to, bring men into that, into that space so that they can benefit from all the wonderful work that you've been doing?

[00:09:10] Kathryn Schmitz: Yeah. So, um, we find that, in the literature what you find is that men are less likely to join group activities, after a cancer diagnosis. and, that's exactly why your organization exists. Um, but, um, we find that we actually do pretty well with, inviting men to do an exercise program because we're doing it with them one-on-one.

[00:09:31] Kathryn Schmitz: and so it's less of a group activity and so there's, there's less of that, you know, that sort of initial barrier that some gents might feel in approaching something that's in a, in a group setting. so that's actually gone really well for us, and one of the places where it's gone particularly well is with our older, patients.

[00:09:50] Kathryn Schmitz: So we have a 12-week telehealth program that we do for older patients and, we find that, our male participants do really, really well and really enjoy the [00:10:00] program. 

[00:10:01] Brad Buchanan: Are there specific activities that men might be more inclined to, engage in, you know, than, than women might? like what, what is working to get them in there and keep them in there?

[00:10:13] Kathryn Schmitz: we're really focused on strength training in the Moving Through Cancer program, because we know that during cancer treatment people tend to lose a lot of lean mass, a lot of muscle mass. and that changes your ability to function and climb stairs and, alters the way that you respond to cancer treatment symptoms as well.

[00:10:32] Kathryn Schmitz: And so, I think one of the reasons why our program has done relatively well, um, with men is because we are focused on something that is more stereotypically associated with, men being interested in the activity. 

[00:10:46] Brad Buchanan: You mean strength, right? Right. 

[00:10:48] Kathryn Schmitz: Yes ... 

[00:10:48] Brad Buchanan: right, that is a classic masculine, uh- Yeah

[00:10:52] Brad Buchanan: gender, um- trait, let's say, that, uh, that, that will appeal to men.

[00:10:57] Muscle- and Bone Mass and Cancer Survivorship

[00:10:57] Brad Buchanan: I'm, I'm also w- [00:11:00] wondering about the long-term survivorship, impact of strength training. just to give my own, patient perspective on that, like, I lost a ton of muscle mass, during my- Mm ... stem cell transplant in particular, 'cause I was basically bedridden for months, in the hospital.

[00:11:17] Kathryn Schmitz: Yeah. 

[00:11:17] Brad Buchanan: And I also lost bone density too, because I was on a lot of prednisone. 

[00:11:22] Kathryn Schmitz: Mm-hmm. 

[00:11:23] Brad Buchanan: and I was diagnosed with osteopenia- Mm ... a few years after my transplant, and, needed, yeah, to, to up my dietary, supplements to compensate for that. I also I think got a- some sort of infusion to address that.

[00:11:40] Brad Buchanan: Mm-hmm ... but also I, you know, my understanding is that, strength training really helps to try to build, 'cause you can recover some bone density. 

[00:11:48] Kathryn Schmitz: You can. 

[00:11:48] Brad Buchanan: and strength training is, is part of that. So I'm wondering if you could just say more about that sort of more, maybe more long-term- 

[00:11:56] Kathryn Schmitz: Sure ... effect of strengthening.

[00:11:57] Kathryn Schmitz: the researcher who's done the most brilliant [00:12:00] work in my view on bone health after cancer is Kerry Winterstone. Kerry has done work both in breast cancer patients as well as prostate cancer patients.

[00:12:10] Kathryn Schmitz: And, you know, one of the things that she has convinced me of based on the results of her research is that, the kinds of things that we need to do in order to, improve bone after cancer, after a, you know, cancer treatment, results in osteopenia and osteoporosis, is a combination of strength training and, activities that load the bone, like jumping or plyometric activities, weight-bearing aerobic activities.

[00:12:37] Kathryn Schmitz: she's done some really brilliant work comparing those kinds of things to things like Tai Chi. what she finds is that, it is more useful for bone. bone as an outcome is becoming of interest again, because we have some new agents that are coming forward, for, breast cancer in particular.

[00:12:53] Kathryn Schmitz: we don't know what their effects are gonna be on bone. we're back in the same position of trying to figure out [00:13:00] exactly how best to help those patients. And what we want is to not wait to see that these women end up with, osteopenia and with, fractures, before we actually act on it.

[00:13:11] Kathryn Schmitz: because we can very reliably predict based on the action of the drug that there are likely to be problems with the newer drugs. in terms of the long-term effects, and I think you're talking about, disease-free, survival overall survival. the, difficulty is that it's, you know, as an epidemiologist I can tell you that there is no really good way to measure, whether people have been doing strength training or not because unlike with aerobic activity we say, "Oh, I ran for an hour," or, "Oh, I ran for 30 minutes."

[00:13:41] Kathryn Schmitz: People know how long they went for something that was high intensity like that. but for strength training we would need people to tell us not just that, "I strength train twice a week," but also how many sets you did, how many reps you did, how intense it was. so there's a great deal more complexity to collecting those data.

[00:13:59] Kathryn Schmitz: So [00:14:00] unfortunately we have really not great data, to tell us whether or not strength training would have an effect on, disease free survival or overall survival. But I suspect based on the biology that it would have, a very strong effect as does aerobic exercise.

[00:14:18] Brad Buchanan: Yeah. Thank you. That makes a lot of sense.

[00:14:20] Plyometric Exercise

[00:14:20] Brad Buchanan: If I could just backtrack and get you to explain what you mean by plyometric- 

[00:14:24] Kathryn Schmitz: Oh, sure ... 

[00:14:25] Brad Buchanan: exercise- That's, that's the thing 

[00:14:26] Kathryn Schmitz: where you 

[00:14:26] Brad Buchanan: like- ... because 

[00:14:26] Kathryn Schmitz: that's a term I- Yeah, jump on a box. 

[00:14:29] Brad Buchanan: Oh, okay. I can't jump like- Yeah ... over my, I can't jump over my cat if my cat- ... is in the way. Like, I've lost any athletic- 

[00:14:38] Kathryn Schmitz: Yeah

[00:14:38] Brad Buchanan: capabilities whatsoever. My knees are shot. Basically I, I can't- Yes ... run because of all the, I think primarily it was the chemotherapy, and radiation that, that, did it for my knees and my, Yeah ... and those particular, joints.

[00:14:52] What If I Don't Feel Strong Enough for Exercise?

[00:14:52] Brad Buchanan: But, what about stretching or, like, yoga or massage- Right ... can any of those things help with any of [00:15:00] these, 'Cause I've personally found a massage has been probably the best way for me to feel like a human being again after my-

[00:15:07] Brad Buchanan: various treatments. Uh, when I- Yeah ... you know, I ended up feeling like I was a sort of a bundle of body parts that had been put together incorrectly. and I- Yeah ... I don't know how common that is among other- 

[00:15:19] Brad Buchanan: cancer patients. It's very common with, stem cell transplant recipients, especially if we've had graft-versus-host disease as I have. But- 

[00:15:26] ... 

[00:15:26] Brad Buchanan: Anyway, I'd like to know more about, yeah, like, stuff that's not maybe so athletic, 'cause like I've lost- Mm-hmm

[00:15:32] Brad Buchanan: all athletic capabilities. I'm not jumping on any boxes, nor 

[00:15:35] Kathryn Schmitz: will- Right. Well, I will, I will guarantee you that if you gave me 15 minutes I could have you doing strength training.

[00:15:42] Kathryn Schmitz: So everyone, everyone can do something with resistance- Absolutely

[00:15:45] Kathryn Schmitz: even if it's in a chair, okay? and should do some kind of strength training. and 'cause if it's, muscle is a use it or lose it principle. so there are still some things that you can do, and, you know, there are weight-bearing things that you could do, that would be good for your [00:16:00] bones, and I would advise it.

[00:16:01] Kathryn Schmitz: In terms of bone health, we have zero evidence that, massage or yoga, would have an impact on bone. In fact, those are things that are used in control groups for the trials. but, in terms of the ability to help with, symptom outcomes, absolutely. so yoga is, is a modality that can be used for, cancer-related fatigue, anxiety and depression.

[00:16:26] Kathryn Schmitz: you know, it has been shown to be efficacious. It's not as well-studied as aerobic exercise and strength training, but it does have value. and massage is really, poorly studied. The kinds of research that I do, which is randomized controlled trials, doesn't tend to happen in the world of integrative medicine, to the same extent.

[00:16:46] Kathryn Schmitz: There's gorgeous data on acupuncture.

[00:16:50] Kathryn Schmitz: Re- really beautiful randomized controlled trials. Rigorous, beautifully done randomized controlled trials about acupuncture. So we know that acupuncture has real value as [00:17:00] well. but the, the quality of the evidence that I call upon in order to say that something is or is not useful I, that evidence doesn't exist for massage.

[00:17:08] Kathryn Schmitz: That doesn't mean it's not useful. It just means we don't have the evidence. 

[00:17:11] Brad Buchanan: Right. Yeah. Well, thank you. No, it, it's, it's really good to hear what the, what the research is telling us at this time and, and yet how, how much more research can potentially- Yes ... tell us. Yes.

[00:17:24] Brad Buchanan: Um, yeah. Um,

[00:17:27] Physiology of Exercise

[00:17:27] Brad Buchanan: I wonder if you could just walk us quickly through, like, how this works physiologically, let's say. You, you mentioned the evidence that shows that doing upper body strength training helps with breast cancer-

[00:17:39] Brad Buchanan: patients. Uh, what's going on in the body physiologically from your point of view when, that's beneficial?

[00:17:45] Brad Buchanan: Just for, to a layman, which I, despite my cancer experiences, uh, there's still a lot of the, terminology that's a little bit opaque.

[00:17:56] Kathryn Schmitz: Sure. Absolutely. So, um,

[00:17:58] Kathryn Schmitz: breast cancer [00:18:00] treatment often includes removal of, lymph nodes, from the chest wall or from the armpit, what's called the axilla.

[00:18:07] Kathryn Schmitz: in addition to that, there's, often radiation treatment to the chest wall or to the armpit as well. And those two things, the removal of the lymph nodes and the irradiation of the lymph nodes can cause damage to, the lymph system in the upper body. And, the way that the lymph system works in the upper body is that, those lymph nodes that are in the chest wall and the armpit are feeding the arm and the hand on the same side.

[00:18:36] Kathryn Schmitz: if the lymph nodes are damaged, then the ability of those lymph nodes to help the hand, and the arm to communicate what they need to communicate back towards the heart, which is, the lymphatic system is a return system back to the heart, is damaged and so what we know from exercise physiology is that if you exercise, a body part, then you are going [00:19:00] to grow more capillaries in that area.

[00:19:02] Kathryn Schmitz: we know that we grow more capillaries where we exercise, and it's very specific. Exercise your left arm, you'll grow capillaries in your left arm. Exercise your right arm, you'll grow capillaries in your right arm, and only your right arm, right? so what we know is that, by doing the upper body exercise, slowly increasing the physiologic stress on the upper body by doing the strength training, then we're probably improving the, cardiovascular system.

[00:19:28] Kathryn Schmitz: We're improving the number of capillaries and vessels that are helping the lymphatic system to return any kind of, debris from cuts or, infection or bacteria or anything that gets into the arm or hand back up the arm and all the way back to the heart so that you don't end up with an infection.

[00:19:48] Kathryn Schmitz: So we believe that there is really kind of a mechanical effect, of the upper body exercise for the, arms and, shoulders and chest and back of, breast cancer [00:20:00] patients. How did, how did I do, Dr. Van Londen? How did I do? 

[00:20:04] G van Londen: You did very good. Uh, one thing I would like to add, oh, but I don't know if I throw too many wrenches in here, is scar tissue.

[00:20:12] Kathryn Schmitz: Oh, yes. Yes. 

[00:20:13] Kathryn Schmitz: So, scar tissue is, is, is a particular challenge, after breast cancer and can, impede range of motion, but also impede the ability of the lymphatic system to do what it needs to do. And so again, by doing slowly progressive resistance training, we can, help that, scar tissue to be able to, loosen over time.

[00:20:36] Kathryn Schmitz: Um, and that can be with not just the strengthening, but also the stretching activities that go with the program that I've developed called Strength After Breast Cancer. It's, it's mechanical, um, even for the, the scar tissue. I think there's a mechanical a- aspect to it as well.

[00:20:52] Payment for Cancer Survivors' Exercise

[00:20:52] G van Londen (2): This is a topic we can talk about for a long time, but , I wanted to delve into something else [00:21:00] that is really near and dear to our hearts is payment.

[00:21:05] G van Londen (2): Kathryn, can you comment on your, hopes and dreams for how cancer survivors can access these, exercise services in terms of payments? Like who will pay for them? 

[00:21:25] Kathryn Schmitz: Yeah. so this has been a topic of interest for me for, the better part of a decade. and the assumption for a very long time had been that, there would always be philanthropic sources that would pay for exercise programs, for cancer patients and survivors.

[00:21:41] Kathryn Schmitz: And, that is still the kind of standard of care, if you will, is that, you know, it should be free, and it should be paid for by philanthropy. And so, health systems shouldn't have to pay anything for it and patients shouldn't have to pay anything for it. And so, it is then devalued.

[00:21:58] Kathryn Schmitz: I believe that with the [00:22:00] results of the challenge trial, which was published last year and showed us that, in a, a very rigorous randomized controlled trial that an exercise program after colon cancer resulted in a 27% improvement in disease-free survival and 38% improvement in overall survival, which is, more whopping effects than for most chemotherapies.

[00:22:22] Kathryn Schmitz: we really need to, flip the script here and, we need exercise to be part of the standard of care for, for cancer patients and survivors. So I've been trying to approach this a number of ways. one of them is through trying to change policies. I've been, very grateful to have the opportunity to learn from, colleagues at the National Accreditation Program for Breast Centers about the process of writing standards and getting, standards to, guide the care for breast patients.

[00:22:54] Kathryn Schmitz: And I've-- they have allowed me to contribute to some of the standards that [00:23:00]exist for NAPBC. and, you know, I'm very proud of the, the collegial work that we've done to develop standards that ask breast programs to, do some kind of evaluation of their patients' upper and lower body function while they're going through their treatment so that they get appropriately referred, whether it's to physical therapy or to an exercise program.

[00:23:22] Kathryn Schmitz: I've also been really, grateful to have the opportunity to work with the, Commission on Cancer on trying to see if perhaps there might be room for an exercise oncology standard at, COC. And so that's, that's an ongoing conversation. Please stay tuned. Um, we'll see what happens with that. I'm hopeful.

[00:23:41] Kathryn Schmitz: Um, and then, closer to home, I have been working with, senior leadership at, U-UPMC to see whether there might be any opportunity for us to make exercise a covered benefit, for breast cancer patients, that are, employees of UPMC and [00:24:00] so an executive committee decided that they were willing to allow this pilot idea to go forward.

[00:24:05] Kathryn Schmitz: And, so now a very large team, led by Dr. Suzanne Labriola, is working on designing this covered benefit and, learning all of the, things that have to be clarified. how are you billing? How are people credentialed? where is it going to occur? Are we working with providers that are outside of UPMC or within UPMC?

[00:24:27] Kathryn Schmitz: what does the training need to be of the people who are gonna be doing this? There's a number of things that have to be clarified in order for this kind of, of covered benefit to become a reality. And so I am so absolutely honored to get the opportunity to collaborate with UPMC on these conversations.

[00:24:45] Kathryn Schmitz: Um, and, um, I can't wait to see where it takes us. 

[00:24:48] G van Londen: It's, it's my understanding, Kathryn, and I get a little excited now, that this is the first time in the United States that a [00:25:00] health plan is considering piloting this with the hope that they will expand it to covering it for every cancer survivor, just like they cover exercise for those with diabetes and those with a history of heart disease.

[00:25:17] Kathryn Schmitz: Yes, that's correct. UPMC is leading the way here

[00:25:20] G van Londen: I'm so excited. Brad, are you excited? 

[00:25:24] Kathryn Schmitz: I am so excited. 

[00:25:25] Brad Buchanan: Well, if I were a breast cancer patient at UPMC, I would be very excited. 

[00:25:30] Kathryn Schmitz: Yes. 

[00:25:31] Brad Buchanan: Yes ... but, uh, no, I mean, obviously someone has to be the first, right? Yeah. Someone needs to, blaze the trail so that others may follow. I certainly applaud these, groundbreaking efforts, on your part, Dr.

[00:25:43] Brad Buchanan: Schmitz. 

[00:25:44] Kathryn Schmitz: Thank you. I'm, you know... It's really, it's been an amazing thing. I came to, University of Pittsburgh, and UPMC Hillman Cancer Center in large part because I saw within this place an opportunity for some entrepreneurship with [00:26:00] regard to changing how we deliver exercise oncology. And so, we've done this whole program that I've talked to you about, which is, supported by Hillman Cancer Center and by some philanthropy.

[00:26:12] Kathryn Schmitz: and now we have this opportunity to collaborate to see if it's possible to create a covered benefit. it's a pilot for right now, and, I have to pinch myself every day talking about it to see, is this really gonna happen? we need to get it right too, because if we get it right, then it will become more broadly available.

[00:26:31] Kathryn Schmitz: It will, form the basis for other health systems to do the same. No pressure. 

[00:26:35] G van Londen (2): No, no, but that's one of the reasons why you're here- Yeah ... to try to inspire and empower other people to do something similar in their communities. it's my belief, and I'm pretty sure, Brad and Kathryn, you think the same, that an early investment will have the payoff later on.

[00:26:57] G van Londen (2): The question is, can we measure that? Can we [00:27:00] prove that? - 

[00:27:01] Kathryn Schmitz: Yes, exactly. So, I can tell you that, one of the reasons why UPMC was willing to consider this was because of some preliminary data that, I published, with, Dr. Karen Wonders, that shows, a potential for improvement in acute unplanned, healthcare utilization with an exercise oncology program, as compared to not doing, an exercise oncology program.

[00:27:24] Kathryn Schmitz: And so, we need further data on this topic. Um, and this is sort of very close to my heart. Um, I'm, I'm trying to figure out how to get some further funding, to examine this. 

[00:27:35] G van Londen: Thank you, Kathryn. We're not done yet, but it sounds like we need to have you as a recurring guest- so you can update us.

[00:27:43] Kathryn Schmitz: I'd 

[00:27:43] Kathryn Schmitz: be delighted.

[00:27:45] The role of medical providers in cancer survivors exercise 

[00:27:45] G van Londen (2): So the, the last topic, we've talked about the exercise providers. Mm-hmm. We've talked about the survivors. Mm-hmm. But then there is an important, a third group involved in this triangle, which is the healthcare [00:28:00] provider, whether it's- Yeah

[00:28:01] G van Londen (2): a cancer provider or a non-cancer provider, like the primary care doctor. and I have a feeling that you have a lot to say about the involvement of providers, and so I'm gonna leave it as broad as I can. 

[00:28:16] Kathryn Schmitz: Yeah. I do have things to say. What I want to say first and most importantly is that I think that, healthcare providers are really stretched these days in the US.

[00:28:27] Kathryn Schmitz: And, I think that's true for, for oncology specialists. I think that's true for primary care providers. and, in an ideal world, they would have a lot of training and understand the power of exercise for their patients, and they would prioritize talking to their patients about exercise and tell their patients that they think it's just as important as their chemotherapy.

[00:28:49] Kathryn Schmitz: that it's just as important as, as, you know, all the other treatments that they're getting. but we don't live in an ideal world, and, clinicians have many, many, many things that they need to [00:29:00] cover in a very short time that they have with their patients. And so I never ever want to make clinicians feel bad or wrong about not remembering to talk about exercise , because I think that, they have a lot of pressures.

[00:29:14] Kathryn Schmitz: what I want is to create the infrastructure so that patients always get support for exercise, and that all the clinicians have to say is, "Oh yeah, you're gonna talk to Dr. Van Londen," or, "Oh, you're gonna talk to Dr. Schmitz," or, "Oh, you're gonna talk to Ray." You know, you're gonna talk to who, you know, whatever.

[00:29:33] Kathryn Schmitz: I want you to do what they say. That's all they need to say. , Like a single sentence. So I want buy-in from the clinicians for sure. I want the clinicians to, rigorously review the literature as I have and say, "Yes, I think this is a good thing for my patients to do."

[00:29:47] Kathryn Schmitz: But for them to have the, the infrastructure, in place to be able to support them in getting their patients, in the same way that they have, you know, there's a huge infrastructure for getting patients to chemotherapy. [00:30:00] Huge infrastructure, right? all those chemo chairs, and the poles, and the nurses, and the medical assistants, and the billers, and the schedulers, and the people walking around with dogs to pet and, you know, hot blankets and snacks and, you know, all of the other things that go along with a chemo infusion suite.

[00:30:19] Kathryn Schmitz: We need to create that infrastructure for exercise oncology. We need to, you know, create that same infrastructure. so that the physician doesn't need to say much more than, "Hey, this is really important, and you're gonna go talk to, Ray about this now."

[00:30:34] G van Londen: Thank you, Kathryn. I think Brad is ready for his questions

[00:30:38] Neuropathy

[00:30:38] Brad Buchanan: A- well, I wanted to say amen to, to what Dr. Schmitz just said, of course. Um, I have a question. I, I guess I'm sort of returning back to a previous conversation, but this time about neuropathy. 

[00:30:51] Kathryn Schmitz: Mm-hmm. 

[00:30:52] Brad Buchanan: which is, you know, maybe the most common, lingering aftereffect, among the men I talk to- 

[00:30:59] Kathryn Schmitz: Yes

[00:30:59] Brad Buchanan: [00:31:00] of their cancer treatments, and I certainly have neuropathy too. 

[00:31:03] Kathryn Schmitz: Mm-hmm. 

[00:31:04] Brad Buchanan: my understanding is that there is no, link between exercise and, improving neuropathy, but I could be missing something. and so I'd love you to fill me in on that. And because I know there are people going into their chemo, treatments, like with, cold packs on their hands and feet hoping to prevent- 

[00:31:23] Kathryn Schmitz: Mm-hmm

[00:31:23] Brad Buchanan: neuropathy. is there any exercise component that would either help to prevent neuropathy from happening in the first place, or then to treat it, or somehow address it after treatment? 

[00:31:36] Kathryn Schmitz: Yeah. So, th- there are some researchers in Europe who've done some beautiful, extremely well-controlled, aerobic and resistance training interventions for peripheral neuropathy that have shown some promising results.

[00:31:49] Kathryn Schmitz: when we then bring that work to the US and people, you know, do the interventions in the US, we're not seeing the same results. We're not quite sure why. Mm. so the, the data are not [00:32:00] consistent, across the ocean. one of the things that seems to have some promising possible, benefit are the vibration plates have you ever heard of vibra- vibration plate?

[00:32:11] Kathryn Schmitz: So the really expensive ones, are like $5,000 and, you go into a facility to do this, and you stand on the plate and it vibrates your feet. and they can fine-tune exactly what, the speed and the depth of the vibration is. and then there's something you can buy off of Amazon for 80 bucks and stand on and it vibrates.

[00:32:31] Kathryn Schmitz: And obviously that's not gonna have the same exact effect. But, there is emerging evidence that there could be some value with the vibration plates. I'm not asking people to go out and get something from Amazon. That is not what I'm getting at right now. but there is, you know, just sort of watch this space.

[00:32:46] Kathryn Schmitz: We'll see what happens. it's been frustrating not to be able to nail down exercise and neuropathy because we get a trial, and we get a positive trial, and we think, "Hey great, this is great." And then we get another trial and it's null. And [00:33:00] so, the people who work in neuropathy, would like us to conclude that it helps.

[00:33:04] Brad Buchanan: May I offer a hypothesis for why- Sure ... there might be a gap between the European results and the North American ones? My understanding isn't, and this is my understanding, again, from a, a layman's perspective, but, having addressed and sat in on, a s- a session of the European Bone Marrow Transplant Association, my understanding is that in Europe, there are maybe fewer cancer and transplant centers per capita, but they are more full service.

[00:33:34] Brad Buchanan: each one has more, of the wraparound stuff, including all the support, you know, a- and wellness enhancement things that we would all like to see at all cancer centers. whereas in the US, it's a little bit of a grab bag. And so, not every cancer center here is as well-equipped, you know, to, to offer, all of the peripheral services that would [00:34:00] make, you know- That would make, an experimental treatment, supplemented by exercise that, that would make it successful.

[00:34:09] Brad Buchanan:

[00:34:09] Kathryn Schmitz: Oh, this is a study that I wanted to design about 15 years ago. I w- I had the good, luck to, have been invited several times to Germany, and got to see their, you know, how cancer is treated in Germany, and, how they do cancer rehabilitation.

[00:34:25] Kathryn Schmitz: Their cancer rehabilitation centers are like spas, and, everybody goes for three weeks, and you get the, the whole treatment. And, and, you know, I, I just was so astounded, and it, it really, it, struck me that, wow, it must be that people recover better from cancer in Germany than they do in the US.

[00:34:46] Kathryn Schmitz: And so I tried really hard to figure out how to design a study to test that. I'm very interested in what you're saying. I never did succeed in designing and getting that study funded, but, I think you're onto something. 

[00:34:57] Brad Buchanan: Dr. Josie, you may have some thoughts. 

[00:34:59] G van Londen (2): [00:35:00] I'm trying to keep it together in my head. So for those that are listening, neuropathy, is damage of the long nerves due to chemotherapy and other treatments. Sometimes it happens for other medical reasons. But it can present with numbness, which is obviously not painful, but can still be bothersome.

[00:35:22] G van Londen (2): There is the painful neuropathy, where you can have pain and burning of your feet and your hands, and, there is the clumsy neuropathy, is what I call it, where sometimes you don't have full control over the motion of your- Feet, fingers, hands, and with that you may lose balance.

[00:35:42] G van Londen (2): And so neuropathy manifests itself in many different ways. And what we also know, to some degree, is that what you eat and how you move is also affecting how your nerves might have a [00:36:00] reserve but also how they may recover. That in Europe, uh, the food, uh, regulations are different than here in the United States.

[00:36:10] G van Londen (2): Obviously, regardless of that, we eat differently here than in Europe. And in Europe, we move a lot more than in the United States. And so I wonder if any of those factors interfere with the ability to see that there is a benefit here in the United States. But I have a feeling this is a, also a discussion that can go on for a long time.

[00:36:37] Kathryn Schmitz: Very long time. 

[00:36:38] G van Londen: I like that you brought this up, Brad. And Kathryn, I'm really happy that you were here to- share what you've been up to, and what you're going to be doing to, shake up the world. And usually towards the end of the hour, I let everybody have their closing statement, if that is how you want to call it.

[00:36:59] G van Londen: Are [00:37:00] there any last words that either of you would like to share before we close for today?

[00:37:06] Kathryn Schmitz: it's important that people move, w- however they move. And if moving for you is sitting on the front of your chair for five minutes, then do that. If moving for you is standing up for five minutes, then do that. If moving for you is 30 minutes of walking, then do that.

[00:37:24] Kathryn Schmitz: I think that, we get stuck on the idea that exercise has to look like CrossFit, um, or has to look like marathon running or 5Ks or whatever. And, exercise can be really minimal, and very useful at a very minimal level. and so, you know, start where you are, do what you can, and, take it from there.

[00:37:45] G van Londen: Thank you, Kathryn. Brad, is there anything else you would like to share? 

[00:37:50] Brad Buchanan: I have found this a fascinating conversation, just in terms of, Dr. Schmitz's, command of the research and, her, innovative, approach on [00:38:00] both a, medical level, but also on an administrative and intellectual level.

[00:38:04] Brad Buchanan: Mm-hmm. but yeah, we've discussed exercise on this podcast before, and yeah, I will just say to go on the record if people haven't listened to that previous one, that, you know, I've lost, the athletic, side of Brad that used to exist when I played soccer and ran every day and so forth.

[00:38:22] Brad Buchanan: I do lift my 10 pound and five pound weights every day and I hate it. I don't enjoy lifting those weights, and my daughters make fun of me because they're such wimpy weights. And then I ride my bike either stationary or out there in the real world, to, to get some of those, leg muscles going.

[00:38:40] Brad Buchanan: And I've gotten to the point where I don't feel right if I haven't had that exercise, even if I'm only spending total of half an hour a day- Yeah ... you know, doing the little that I can do. 

[00:38:51] Brad Buchanan: And yeah, I, I really do think it's, it's played a huge role in, in my, slow and somewhat unsteady recovery over [00:39:00] these past 10 years. 

[00:39:01] Kathryn Schmitz: But you have recovered. 

[00:39:03] Brad Buchanan: Well, I've recovered to some extent. I'm still in recovery and- 

[00:39:07] Kathryn Schmitz: Yeah ... 

[00:39:08] Brad Buchanan: but yeah, I'm never gonna get back to, running great sprints or whatnot.

[00:39:12] Brad Buchanan: That's just not on the cards. But I'm learning to accept that, that doing a small amount is way better than doing nothing. 

[00:39:21] Kathryn Schmitz: True. There you go. Well 

[00:39:23] G van Londen: said. Thank you. Thank you both. 

[00:39:25] Kathryn Schmitz: Absolutely. Thanks for having- Thanks for the invitation. This was really fun.