Ask Paul Guenard how he’s doing and he’ll tell you, “Not bad for a guy who’s supposed to be dead!”
While he laughs as he says it, Guenard did indeed face death six years ago when he underwent a stem cell transplant to treat mantle cell lymphoma. Afterwards, he said, he felt so weak he “couldn’t open a can of pop.”
But he agreed to take part in a unique cardiac rehabilitation program designed at the University of Alberta to help cancer patients who also face heart damage due to their treatment. The fitness training helped Guenard regain his strength—but more important, it gave him hope.
“One of the issues with cancer or heart disease for a lot of people is psychological helplessness,” Guenard said. “To have somebody there telling you that you can get better is very important.”
Physical and psychological benefits
The program is the brainchild of Edith Pituskin, associate professor in the Faculty of Nursing, associate clinical professor of oncology in the Faculty of Medicine & Dentistry and Canada Research Chair (Tier 2) in chronic disease, who decided to start it as a trial program after being told it would be unethical to ask such sick patients to take on a physical exercise regime.
Six years later, it is now standard practice for patients from Edmonton’s Cross Cancer Institute who have had autologous transplants (using stem cells from their own bone marrow or blood) to take part in cardiac rehabilitation, thanks to a partnership with the Jim Pattison Centre for Heart Health within the Mazankowski Alberta Heart Institute.
“We are the first to report not just the physical benefits but psychological benefits of supportive rehabilitation in a very high-risk cancer population,” said Pituskin.
“No such program exists anywhere else,” she noted. “This is something that can change and improve people’s lives.”
A double whammy for the heart
More than 50,000 people around the world receive a stem cell transplant each year. They face an increased risk of future heart problems due not only to chemotherapy and radiation that can be toxic to the heart, but also to being bedridden for weeks following the transplant.
“We explain to patients, what we’re giving you is a chemo attack, not a heart attack, enough that it will damage your heart,” said Nanette Cox-Kennett, nurse practitioner and autologous transplant program lead at the Cross Cancer Institute. “To speed recovery and keep you healthy, we know that exercise is beneficial.”
Patient fitness—including grip strength, gait speed, how long it takes to get out of a chair (“timed up and go”) and how far they can walk in six minutes—is assessed before transplant, after transplant, at the outset of the rehab program and after completion. The patients do eight weeks of supervised moderate aerobic activities and resistance training, and also attend classes about cardiac health topics such as diet, stress and weight management.
Statistically significant improvements were found in grip strength, gait speed and the six-minute walk test for the first 30 patients, the researchers reported in a 2018 paper published in the Canadian Journal of Cardiology. Their attendance was 57 per cent, a number that can be as low as 30 per cent for regular cardiac rehab patients. Ten of the patients were also interviewed for a followup paper, which will soon be published in the Journal of Cardiopulmonary Rehabilitation and Prevention.
“Overall, we found this program helped patients cope during the recovery period,” said first author and nurse practitioner Derek Rothe, who developed the project for his master’s thesis. “It gave them goals to set, and motivation to get more active and regain their functional status.”
Three themes emerged from the patient interviews, Rothe said. For most of the patients, immediate recovery from their transplant was more of a motivator than their risk of future heart disease. Those who had been previously active made the rehab program a priority. And observing the initial loss of fitness following transplant and then the tangible improvements during rehab motivated them to keep going.
Patients in the study reported how much they appreciated the support and encouragement of the rehab program staff, a multidisciplinary team of exercise physiologists, dietitians, social workers, pharmacists, nurses and cardiologists.
“They were outstanding,” said Guenard. “Their positive attitude was infectious.”
Exercise as medicine
The research was supported by the Jim Pattison Foundation and the University Hospital Foundation, and was made possible by trainee awards for Rothe from the Elaine Antoniuk Graduate Nursing Scholarship, Maurice and Edna Minton Endowment Fund, Aplastic Anemia and Myelodysplasia Association of Canada Scholarship, Canadian Nurses Foundation, Liz Lemire Memorial Scholarship, Alberta Registered Nurses Education Trust and the Dean’s Discretionary Fund at the U of A. Cox-Kennett also received the Maurice and Edna Endowment Fund in 2004 when doing her master’s thesis. Pituskin is a member of the Women’s and Children’s Health Research Institute.
Pituskin said the next step will be to follow patients long-term to track their cardiac health outcomes. She also wants to offer the rehab program to an even higher-risk group of cancer transplant patients: those who receive stem cells from donors (allogeneic), as they face higher doses of chemotherapy and longer hospital stays.
“We are hoping to develop a pre-hab program so they can receive careful exercise advice that’s personalized to them while they are waiting for transplant,” she explained.
As for Guenard, the former bush pilot, shop teacher and McDonald’s restaurant franchisee usually enjoys cycling and kayaking in Florida each winter. He got his commercial pilot’s licence back, took up sailing, and over the COVID winter he rebuilt the exercise room in his Peace River home.
“When you get this kind of diagnosis, and they tell you you’ll have a bad heart on top of it all, it would be very easy to go home and feel sorry for yourself and give up,” he said.
“I refuse to let it slow me down, so I run my life as though I’m going to live for a hundred years.”