1. Interventions to Improve Physical Activity and Fatigue for Older Patients Receiving Cancer Treatment Karen M. Mustian, Ph.D., M.P.H. Director and Associate Professor RENEW Exercise and Wellness Program for Cancer Patients and Survivors PEAK Human Performance Clinical Research Laboratory URCC NCORP Research Base Department of Surgery

2. Exercise is Medicine Decrease toxicities and side effects of cancer and its treatments –Fatigue, emesis, nausea, infections, inflammation, immunosuppression, depression, insomnia, cognitive impairment, sarcopenia, loss of physical function Decrease recurrence and second cancers Improve quality of life Improve survival

3. EXCAP ©® Home-Based Exercise for Older Prostate Cancer Patients

4. EXCAP ©® Intervention

5. EXCAP ©® Adherence & Adverse Events ControlsExercisers Baseline Average Daily Steps 58616548 Post-Intervention Average Daily Steps 24717180 Baseline Average Number of Minutes and Days of Resistance Bands 0/0 Post-Intervention Average Number of Days/Minutes Per Day of Resistance Bands 0/53/22 Adverse Events 1 AE/8SAE2AE/7SAE Adherence was very good with 34 (97%) of the participants assigned to the EXCAP ©® group completing the steps and resistance exercises. No AEs or SAEs were determined to be study-related; all were due to the patient’s prostate cancer or other comorbidities.

6. Results (N=58) (Mustian et al., 2009 and Sprod et. al. 2010, Mustian et. al., 2013, Mustian et. al., 2014) Intervention improved: –Cancer-related fatigue –Cardiopulmonary function –Strength –QOL –Improved sleep –Maintained muscle mass –Reduced Inflammation –Increased expression of genes supporting muscle growth, metabolism and immune function

7. YOCAS ® Yoga Significantly Improves Sleep, Anxiety, Mood, Memory, Bone Pain and Circadian Rhythm in 97 Cancer Survivors Over Age 60 (Mustian, et al. 2013, Sprod et al. 2014, Janelsins et al. 2015, Peppone et al. 2015)

8. YOCAS ® Intervention

9. YOCAS ® Yoga improved –Fatigue (physical and mental) –Insomnia –Sleep quality –Anxiety –Mood –Memory –Arthralgia and pain –Global Toxicity/Side Effect Burden –Quality of life –Reducing Sleep Medication Use! –Circadian rhythm profiles! Summary It worked in older adults too!

10. Research and Knowledge Gaps GAP 1: Lack of CTs with older adults –Lack of randomized and non-randomized trials among older adults –Eligibility criteria exclude older adults –Uniqueness and complexity of older adults Co-morbidities/super healthy Functional capacity –No trials focused solely on older adults –No large clinical trials with planned and powered subgroup analyses

11. Research and Knowledge Gaps GAP 2: No tailored exercise interventions for this unique population –Dose ModeFrequencyDurationIntensity Progressive tailoring Patient preferences –Dose required to target cancer-and treatment- specific outcomes Biological pathways Mental health Social health

12. Research and Knowledge Gaps GAP 3: No tailored exercise intervention delivery methods for this unique population –Implementation/Delivery Self-directedGroupHome-based Clinic, community, retirement communities, assisted living eHealth and mHealth Personalized medicine approach –moderators and mediators of intervention efficacy and effectiveness

13. Research and Knowledge Gaps GAP 4: Lack of appropriate outcomes –Target Cancer- and Treatment-specific outcomes –Age-specific outcomes –Functional status outcomes –Co-morbidity outcomes –Psychosocial outcomes

14. Research and Knowledge Gaps GAP 5: Lack of appropriate measures –Age appropriate functional measures –Biological measures –Clinical measures –Patient-reported measures –Care-partner measures

15. Research and Knowledge Gaps GAP 6: No attention to health disparities –Intersections of race, ethnicity, education, socio-economic status, sexual orientation, immigrant status, language barriers, etc GAP 7: No attention to care-partner and other social support issues –Patient as care receiver –Patient as care provider –Dyadic intervention approaches –Other social support approaches

16. Research and Knowledge Gaps GAP 8: No cost benefit analyses –Cost to health care system, patients and care-partners –Benefits to healthcare systems, patients and care-partners GAP 9: No training for healthcare professionals –Undergraduate, graduate and post- graduate training –Continuing education training