Andrés Gómez-De León: Welcome back to ASTCT Talks. My name is Andrés Gómez-De León. I'm a physician at Universidad Autónoma de Nuevo León in Monterey, Mexico. And I'm also a member of the ASTCT Content Committee.
I'm very happy to introduce Dr. Miguel-Angel Perales, who is the President of ASTCT. And he joins me now to record his October's President Message, which will be focused on the importance of physical activity and exercise on hematopoietic and cell therapy transplant recipients. Welcome, Dr. Perales.
Miguel Perales: Hi everyone. It’s great to be with you here today, Andrés.
Andrés Gómez-De León: Today's mission is to discuss some of the challenges faced by individuals undergoing transplant and cell therapy when it comes to maintaining their physical activity. So what is your experience as a physician seeing as how neither of us are really experts on physical activity, but we do transplant a lot of patients. What is your experience with this issue?
Miguel Perales: I think this is really an area where we're starting to sort of recognize the importance of this over the last few years, and I think several factors have contributed to that. Number one, we're treating older patients than we used to and certainly they're at a high risk for complications post-transplant; and they already come into the transplant sometimes with a frailty syndrome, which increases their risk of having post-transplant complications related to lack of physical activity. And, you know, the quality of life issues and the long-term outcomes of patients increasingly have also been recognized as being important, not just clinically, but also as areas of research. And particularly the recognition that fatigue is one of the main complaints that our patients face post-transplant, both after autologous and allogeneic transplants, and increasingly as we get into the CAR-T field, also in that setting. A lot of that has to do with deconditioning and lack of physical activity during what, in many cases, ends up being a pretty prolonged hospital stay for patients. And this is exacerbated by many of the things that we do in terms of, particularly patients with graft-versus-host disease, and prolonged use of steroids, which lead to bone loss, muscle loss, and other complications. So a lot of the problem is what we as a clinical team do to the patients, and we recognize that this is really a problem that the patients deal with and that we need to sort of think proactively about how to prevent some of these issues.
Andrés Gómez-De León: Definitely, I agree. And there are a lot of studies out there that have shown that patients that are better physically end up doing better in the short and the long term. So how can we assess or how do you assess this status among patients when you treat them?
Miguel Perales: So again, I think this is an area where there's probably some gaps in our knowledge. There's certainly a recognition in oncology and in the treatment of cancer patients and it has been researched in this area around physical activity, exercise, long-term outcomes for patients and the benefit particularly of physical activity and exercise in cancer patients. But I think, because of the smaller numbers of patients that we treat, there is probably not as much research specifically in transplant. Although I would say, I would make the case that, in many cases these are probably some of the highest risk patients in this regard. And I think the notion of rehab but also of pre-hab is really something that we're recognizing and that whatever we can do to get the patients ready for transplant before they are even admitted to the hospital, including an exercise program that they can start to adopt before admission, and then having active exercise programs working with physical therapy and rehab during the admission, that could only help in their recovery. That's something that in my clinical practice I routinely tell patients when I'm rounding on the inpatient service, that whatever they can do in terms of physical activity during the admission is going to help them once they go home after the transplant. And particularly encouraging them to walk around. I think something as simple as changing practice. For example, a few years ago, for allogeneic transplant, we used to confine the patients to their room during the whole admission in terms of infection control and not exposing them to increased risk of infections. But we realized that that really meant that they were very limited in terms of their physical activity. And so overnight we allowed them to walk the hallways during their transplant, as the autologous patients had been doing for a while. And we sort of saw that when patients were much more active that helped in their recovery, so sometimes very simple measures can make a difference.
Andrés Gómez-De León: That's great, and I think in a lot of institutions, still patients remain confined to their units. At least speaking from my experience here in my city. In Mexico, a lot of patients are very scared to even leave their own room and are worried more about infections than about laying in bed all day, even if the transplant toxicities aren't putting them in bed, necessarily. And think that's a problem on hospital design. It is something that we've had lagging behind decades and even more than a century that patients in the hospital need to be laying in bed because they are sick, you know, a lot of patients that do inpatient transplant and even if they are just receiving the filgrastim mobilization and they go and they lay in bed much more hours than they do when they're at home. So we need to be a part of the team that gives a message that they should keep moving. I love this concept of pre-hab because sometimes we talk a lot about the toxicities but not about the functional capacity that patients may lose when they go to the hospital. And we've seen all of these associations of patients' fitness, whether it's a physical measure test or even an imaging scan where we measure the amount of muscle mass and so on. It's often those patients that are fitter that do better because it has a lot of meaning to a lot of other variables within them. And the work really begins before the transplant when we are talking with the patient if the disease allows to get them to prepare for the procedure.
Miguel Perales: And I think the other point you make is that, as much as we are able to do outpatient transplant, we certainly see that the patients recover faster. The mere fact that they have to come to the center every day for their evaluation, and typically they are relatively close by, but just that commute and the fact that they are not staying in bed all day has a big impact. So trying to move patients to the outpatient setting certainly helps as well.
Andrés Gómez-De León: Right. Now talking about guidance for clinicians, we often lack a lot of hard data and clinical trials and how we should best counsel patients on the best practices during and after the procedure. Why do you think there is a gap in the research in this space?
Miguel Perales: I think this is really where we have the biggest issue unfortunately. I think all of us feel comfortable telling patients to walk and exercise and be active during their transplant. How much of that is based on specific data, I think that's where we have to work with our colleagues on the rehab service and even beyond that, with an exercise physiologist to really advise a program that's geared towards a transplant patient. So we certainly at MSK have people like Lee Jones (https://www.mskcc.org/research-areas/labs/lee-jones) and Jessica Scott, who's also worked with NASA (https://www.mskcc.org/research-advantage/meet-researchers/nasa-msk-work-exercise-physiologist-jessica-scott), who are experts in this and we try to engage with them in devising programs that our patients can use in collaboration with physical therapy and rehab medicine. And I think, you know, the NASA work is interesting because obviously this is something that the space agencies have a big interest in in terms of, what's the effect of weightlessness. And they have actually paid people to do these bed studies where people are paid to live in bed for 30 days or 60 days just to mimic what it would be like to be on the spaceship. And unfortunately our patients are sometimes in that same situation where they may be in bed for 30 days. And so I think that's a good model for us to understand the effects even if you take, you know, quote unquote, young healthy people, young healthy adults and stick them in bed for 30 days, you know how that impacts their muscle weight, their muscle strength, their physiology. And then imagine that in a patient who has cancer, who's also receiving chemotherapy and antibiotics, and may have metabolic changes related to the transplants, how those effects are amplified.
Andrés Gómez-De León: Right, I think it's interesting that we still don't know and perhaps there's also an issue with funding and the fact that there's not a lot of private interests in developing these strategies. It's as similar as in clinical nutrition maybe.
Miguel Perales: No, I agree. Maybe some of the companies that make exercise bikes could be interested in this type of research.
Andrés Gómez-De León: Defnitely. So speaking from a low-middle income country perspective, I hear about your experts in exercising in MSK, and sometimes the issue we have on this side of the world is that the transplant physician, he is the nurse practitioner and he's also the person that you know you are your own infectious disease doctor and you do everything. And you also need to be the expert in physical therapy so we wear many hats and this is an important one that I think we need to delve a little deeper on, and especially since this is not probably a very expensive intervention so this is an area that is very fertile for performing research in even low resource settings because you don't have to buy an expensive drug or an expensive lab reagent or even a novel method. You just need to put patients in physical activity and devise a way to measure and probably to randomize interventions, which is not expensive at all. So it's a gap, but it's an opportunity for us to develop more information on this issue.
Miguel Perales: I agree. One issue is also staffing, right? Because there are certainly patients who are motivated and who will be up there every morning, walking the whole way. For example, at MSK 14 laps around the floor is one mile. And so that’s a metric that we give patients. You can walk into a room at 8 a.m. and somebody’s already done their mile and is preparing to do another mile in the afternoon. And then you have patients who don’t even do one round around the floor. And the only time they may leave the room is when physical therapy comes to see them. And so then you get into the issue of, do you have physical therapy every day? Is physical therapy working on weekends. And so it also becomes a staffing issue because for the patients who are frailer, they're not able to get out and walk by themselves and they need that support. And so then you're very much dependent on staffing issues. If your nurses are busy and your assistants are busy, and there's no dedicated physical therapy, who's going to walk with your patients? That's true, not just in Mexico, but also in U.S. centers.
Andrés Gómez-De León: Definitely, and what about after hospital? There's only so much you can do while patients are in the hospital, with all of the complications and the difficulties and challenges that come with a transplant, it's sometimes very difficult to ask patients to get moving, especially in the more critical parts of the procedure. But even I'd argue it's even harder at home where patients are not in contact with the treatment team as often as they are while they're in hospital. So I'd argue that that's the moment that's probably most important, the after care and after patients are discharged.
Miguel Perales: I agree. I think that's why it's important to really assess the patients, both on admission and on discharge and sort of have an idea of how much they've lost in terms of conditioning and exercise tolerance and then devise a discharge map for patients that may include physical therapy, rehab, even outpatient or at home. And so we certainly try and do that for our patients. But again, that also requires participation of the patient and willingness to participate.
Andrés Gómez-De León: Right. I always remember a patient of mine that had myelofibrosis and he was very consumed by the disease. After the transplant, he had a successful outcome, fortunately. And then he became a gym enthusiast. So he became so fit and had muscles like Arnold Schwarzenegger. Then when he came back, we didn't recognize him because he had gotten his life back and was now very into fitness and that was even without our intervention.
Miguel Perales: Yeah, there's definitely examples like that. I actually have in my office the medal of a half marathon that one of my patients ran, 11 months after an allogeneic transplant. So he had I would say a normal transplant course with an admission of probably four to five weeks and then 11 months later he ran a fundraising marathon for the Leukemia and Lymphoma Society, and that medal sits in my office. And then I have another patient who actually has run several marathons post-transplant, so there's definitely a spectrum in terms of what patients do after the transplant.
Andrés Gómez-De León: And patients sometimes can also have the doctors and the treatment team to get themselves moving and I find that very inspiring. What do you do for yourself?
Miguel Perales: So one of the things that MSK did this year to get people moving was to have a month-long program at the institution that people could sign up for where you could log your daily activity. And it was a point-based system and they had teams of eight individuals so it became very competitive. And within the transplant team I think we had six or seven teams so many people signed up and it was a mix of obviously different people from the team. And you would see every day what others were doing and I had some colleagues who at 11:30 at night were walking outside to make sure they could maximize their points for the day because there was a maximum you could get for the day. So I think that was a great way to motivate people, and we were actually discussing if there was a way to include patients in that type of exercise challenge. Of course, it's a one-month challenge and then if you do nothing for the next three months, it's not that helpful, but hopefully it sort of introduces healthy habits to people. The other problem too is if you haven't exercised and then you start a challenge like that, there are actually some people who got injuries and you know had muscle strains and things like that.
Andrés Gómez-De León: Right, always consult with your physician and your physical therapy experts before these types of gamification. So what message would you like to convey to our listeners to encourage them to keep on moving?
Miguel Perales: So I think it's important for everybody to move, not just the patients but also the clinical teams so that they stay healthy and fit to take care of our patients. And I think we really need to encourage our patients to exercise. We need to provide them with the right tools, before transplant, during transplant, and after transplant as you mentioned. And definitely I think it's an area where we need more research, in terms of the impact of the transplant on patients, and how we can mitigate those impacts and improve the outcomes and the quality of life.
Andrés Gómez-De León: All right, so thanks a lot for your time and for discussing this important issue. This was Dr. Miguel Perales MD, president of ASTCT with his October's President Message.
I'm Andrés Gómez-De León and this was ASTCT Talks.