Dr. Kim Dittus tells us about the benefits of exercise on patients who have completed their cancer treatments and introduces us to Steps to Wellness, a program at the UVM Medical Center that helps cancer patients get their energy back. Listen to the interview or read the transcript below.

UVM Medical Center:  Many people finished with cancer treatments can be tired, weak and stressed out, and you can understand why folks in that situation would not feel like exercising, but it turns out that exercise can improve all of those things and it offers additional benefits. We know this because of a program at the UVM Cancer Center called Steps to Wellness that has served more than 700 patients since it began five years ago. With us today to fill us in on this interesting approach is oncologist and hematologist Dr. Kim Dittus of the UVM Cancer Center’s Steps to Wellness program. She is also medical director of oncology rehabilitation and an assistant professor at the Larner College of Medicine. Thanks for coming.

Dr. Kim Dittus: Thank you for having me.

UVM Medical Center: So add to that very brief overview of Steps to Wellness.

Dr. Kim Dittus: Well you said it very well, so I think a good example of how exercise has benefited individuals with chronic disease is cardiac rehabilitation, and we have had cardiac rehabilitation available and paid for by insurance for years but individuals with cancer suffer similar issues in terms of declines in aerobic function and strength after they’ve received treatment, and so it just seemed to me after seeing so many patients working hard to get back to the way they were prior to their cancer or at least improving, it seemed to me that it was really important to develop a similar program where individuals who’ve had cancer can regain their strength in fitness and function.

UVM Medical Center: We should probably back up and say – so this is the effects both of chemotherapy and radiation, or just chemo?

Dr. Kim Dittus: Yes. So we know that the more treatment an individual receives the greater the impact on your body, so if individuals receive multi-modality treatment like many cancers do, there is a greater impact on fitness and function and strength, that’s for sure.

UVM Medical Center: How depleted, are some cancer patients after long treatment, particularly?

Dr. Kim Dittus: That really is so dependent on what individuals come to their therapy with. If individuals are fairly fit to begin with, they generally can handle therapy better and honestly individuals who stay active during treatment also handle it better. But the biggest risk factor for developing cancer is age, and I think in particular, individuals who are older have a harder time bouncing back. We know that in our oncology rehab program, exercise results in improvements for individuals who are older, including improvements in things like balance and ability to get up and out of a chair – all very important for helping to maintain people’s function as they get older and keep them safe at home and not falling.

UVM Medical Center: So how does this work? Once you’re in Steps to Wellness what happens?

Dr. Kim Dittus: The process is that someone refers you to the program – or if individuals are interested and get our telephone number which is available in our flyers they call – and we set them up for an appointment and they receive an evaluation with a physician or a medical provider to assess any latent long-term effects that might need to be dealt with prior to them exercising. They also then meet with a physical therapist who further assesses whether they need range of motion training or balance training or just more deconditioning before they can exercise on their own.

Then I would say 90% of the time, 85 or 90% of the time, individuals pass those sort of steps and are able to exercise with us at the gym, which is at cardiac rehab on Tilley Drive. After they pass those tests, they meet with the exercise trainers to sort of gear up to what exercise they will be doing in the gym and then they attend sessions twice a week for 12 weeks. The exercise portion includes both aerobic exercise and resistance training, because both are really important for cancer survivors.

Then if individuals were found to have some balance deficits, we also include that within that 12 weeks. The exercise trainers are there the whole time, and they help to advance the program so that individuals push themselves more.

UVM Medical Center: You say resistance training, that’s like muscle building and strength?

Dr. Kim Dittus: Yes, weight training, and we do that mostly with free weights and body weight, some resistance bands and there are some machines out there as well.

UVM Medical Center: And part of what’s interesting is it’s done in a group setting. You’re talking about a lot of individual evaluation, developing a program but they can be part of a group exercise situation?

Dr. Kim Dittus: Yes, so it’s not like a group exercise where you go to a Zumba class or something like that. But individuals start the program in groups of four to six and then they roll into what’s already going on in the gym, so they get to know individuals in the gym really quite well. And one of the things that I found out right from the beginning is that the group interaction was just as important as the exercise – and I always thought it was all about the exercise – but they maintain some very close bonds and friendships.

UVM Medical Center: I would think that’s important because being in a gym environment can be intimidating to anybody. I would think particularly if you’re feeling like you’re not yourself, you’re weaker, you’re not sure what you can do – you would be even more hesitant to get involved. But then you walk in and there are other people in your situation.

Dr. Kim Dittus: Yes, I think it’s a really good model. And so if people don’t feel like they can do it, they don’t usually go to a gym setting, they meet a lot of people who also aren’t used to going to a gym setting and aren’t gym rats, and they see people who are improving right along with them and I think it’s very motivating.

The other thing that has happened with this program is that we have, to some extent, merged with cardiac rehabilitation and pulmonary rehabilitation, so there are people with a variety of chronic diseases who are exercising at the same time, which I find really nice because it just shows that there are many individuals who need to work at improving their lifestyle.

UVM Medical Center: That’s Dr. Kim Dittus, a hematologist oncologist at the UVM Medical Center and involved in the UVM Cancer Center’s Steps to Wellness program – that’s what we’re talking about today. We’re learning basically about how people who have finished treatment can get back on track with developing some strength and endurance and feeling better, and there’s also mental benefits, not just physical, right?

Dr. Kim Dittus: Yes, it’s almost like a group session to talk about stress and those sort of issues. But as well we have education components as part of the 12 week exercise program where individuals meet with someone to deal with stress-related issues and mindfulness, so we incorporate that in a more formal way in addition to what individuals receive from helping each other.

UVM Medical Center: I understand there’s also help with diet and some other healthy behaviors?

Dr. Kim Dittus: Yes, we have a nutrition class where we talk about diet related to cancer and chronic diseases, and then for individuals who have more of a concern about losing weight. There’s a four-session weight management course. One of the other things that the program has really provided is a platform for research for individuals at the University of Vermont. Not just me, but other individuals as well, and so we have some more formalized weight loss programs that are available out there as well.

UVM Medical Center: So what have you learned overall in your research, because each one of these folks is, you do measurements and evaluations and so forth, right?

Dr. Kim Dittus: Yes, we find that strength improves significantly as a result of the 12 week program. Their aerobic capacity also improves. More importantly in terms of how a cancer patient feels in terms of latent lingering effects, fatigue decreases significantly. Anxiety and depression also decrease significant as well. I guess what I’m most excited about is the improvements that the older individuals receive. One of the tests that we do is a test to measure strength just to get up and out of a chair and again a really good marker of individuals’ ability to maintain function in the community and a predictor of falls. When we measure individuals who are aged 65 or older – when we looked at the 200-some that have gone through the program – 25% actually have problems getting up and out of the chair in a time that would be considered normal. At the end of the intervention that number decreases to 5% which I think has really important implications for long-term maintenance of independence.

UVM Medical Center: I’m listening to this thinking that it’s surprising in a way that just twice a week being involved in this kind of activity can have such an important impact on folks.

Dr. Kim Dittus: For strength particularly, perhaps we don’t need to do every day interventions. And strength training is only recommended twice a week, so I think that the improvements in the strength as a result of the program are probably more than what the improvements are for the aerobic capacity. But we do encourage individuals to exercise outside of the program.

UVM Medical Center: Which leads me to the fact this is 12 weeks, as we mentioned, and it’s free, right? Folks don’t have a cost involved but they can also continue after it’s over by going to the same gym at Tilly Drive, right?

Dr. Kim Dittus: Yes. Individuals who graduate can continue if they choose to, but there is a small fee for that. We also have other programs to help individuals continue on a track for making lifestyle change. There’s a health coaching program where individuals who perhaps even can’t come to Tilly Drive and participate in Steps to Wellness – because they live in upstate New York or further away – they can participate in the health coaching program. And a UVM researcher is looking at the use of cell phones and technology to help individuals continue to be active after they finish the Steps to Wellness exercise program.

UVM Medical Center: So you don’t have to be a patient of the UVM Cancer Center to be involved in this?

Dr. Kim Dittus: No. Anybody who has a diagnosis of cancer or hematologic issues can participate, certainly.

UVM Medical Center: I think I was also reading that you don’t have to be just finished with treatment, right?

Dr. Kim Dittus: No – individuals who for example are really motivated to maintain their function during therapy can participate. Most of the time people do wait until after they’re done with their intensive part of their cancer therapy, but individuals who have finished cancer therapy five or more years ago who find us are also welcome.

UVM Medical Center: So when you started this, did it go against conventional wisdom to put people in an exercise program?

Dr. Kim Dittus: Not really. When I started this, the news about all the benefits of exercise for cancer survivors was beginning to emerge. A really important study that was done in 2005 using research completed at Harvard indicated that individuals who were more physically active were less likely to have their breast cancer come back, and so that really spurred a lot of research in the area of exercise. It was an emerging field at that time.

UVM Medical Center: And diet too is a big piece of this, right?

Dr. Kim Dittus: More important perhaps than diet is maintaining a healthy weight. We know that individuals with excess weight are more likely to develop a number of different types of cancers. Similarly individuals who then maintain excess weight after cancer therapy are also at higher risk for having their cancers come back, and have higher risk of dying of other chronic diseases such as cardiovascular disease. So maintaining a healthy weight is important.

UVM Medical Center: Another thing I was wondering about is you hear about “chemo brain” after a longer treatment plan. Do you see an improvement in that, or do you think that’s a real thing?

Dr. Kim Dittus: I do think that’s a real thing and actually that was one of the first studies that I was involved in when I became an attending here – looking at the impact of chemotherapy on cognitive function. We do see that individuals’ cognitive function changes as a result of therapy, in particular it appears that it’s executive function. So it’s not like chemotherapy causes dementia or things like that, but individuals who have completed chemotherapy often feel that it’s more difficult to keep multiple balls in the air and do that sort of advanced planning that might be necessarily for their job, or even necessarily for making lifestyle changes.

Now, the majority of individuals may feel that way for a month up to a year after therapy and then they feel like they pretty much get back to normal. But not everybody does, and so we have recently developed a program where individuals with cancer-related cognitive dysfunction meet with individuals in speech and language therapy at the University of Vermont Medical Center. Moira Mulligan is the person who is spearheading that, and I find that is very nice because we’ve been able to do testing and say, “You don’t have dementia,” but we haven’t had a program to actually help individuals deal with those issues and that’s what she’s doing.

UVM Medical Center: So more improvements and changes as you go forward.

Dr. Kim Dittus: Right – and we also know from other research – not research that’s done out at Steps to Wellness but other research – that exercise improves cognitive function in dementia and in individuals who are older, and in other settings as well.

UVM Medical Center: So, unfortunately folks who don’t like exercise – you hear this about every condition, practically. Heart health, everything else – exercise is really important so you’ll have to keep that in mind.

Sorry to say we’re out of time but I want to thank our guest today. Dr. Kim Dittus is a hematologist oncologist and medical director of oncology rehabilitation at the UVM Medical Center and UVM Cancer Center and she’s been involved in the Steps to Wellness program. She’s also an assistant professor at the Larner College of Medicine at the University of Vermont. Thanks very much for coming.

Dr. Kim Dittus: Thank you for having me. And I’d also like to thank all of those individuals who have donated funds to help keep our Steps to Wellness program going, in particular the Victoria Buffum fund and Jane Landy. And in the last several years, the University of Vermont medical student running team raises money for onc rehab and Steps to Wellness through running the marathon.

UVM Medical Center: And if you want to learn more about how to donate, or just the program in general, you can go to uvmhealth.org/medcenter and search on Steps to Wellness.



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