Standing up to Cancer
"I saw a proverb that says, ‘If you’re not eating well and taking care of yourself, you’re wasting your doctor’s time,’”Potoula Rakis-Lambroulis, a cancer patient who has participated in the Hannaford grocery store tours arranged by Dr. Patel
As excited as Potoula Rakis-Lambroulis was to learn karate, her first class was difficult. She couldn’t kick the bag and catching a weighted ball in a crouched position felt awkward at best. Now, just five weeks into class, both moves are “no problem.” That’s a real achievement. Rakis-Lambroulis is recovering from breast cancer surgery and chemotherapy.
Rakis-Lambroulis’ karate classes are one part of the Dartmouth-Hitchcock (D-H) Breast Cancer Program’s strategy to close gaps in cancer care delivery, improve patients’ overall health and reduce the risk of reoccurrence. Roshani Patel, MD, FACS, began building the program six years ago along with her team, which includes Todd Noce, DO, Radiology; Steven Birmbaum, MD, Radiology; Steven Kammann, MD, Radiology; Carol Walsh, MS, LGC, Medical Genetics; and Josh Rifkind, MD, Medical Oncology.
“Our first goal as a team is to make sure that cancers aren’t missed,” Patel says. “Dr. Noce and I streamlined our radiology workups, which we now do here at D-H Manchester rather than sending patients off-site. Our radiologists always go through the imaging with patients. It’s an old school approach. Technology doesn’t take us away from being doctors, and it makes a big difference,” she says.
Cancer care, however, goes beyond diagnosis, surgery and treatment. When extensive surgery is required under the arm, radiation and chemotherapy can exacerbate lymphedema (arm swelling). Obesity can make lymphedema even worse. Post-surgical scarring and pain affect range of motion. Some medications cause joint and muscle pain. And chemotherapy can cause neuropathy.
“Research shows that early intervention and strength training can decrease lymphedema by 50 percent,” says Patel. “Exercise reduces the chance of cancer reoccurrence by 34-50 percent. We’re invested in outcomes. We want to give patients exercise and nutrition tools that can help improve their survival and decrease disease.”
Adding exercise and nutrition to the recovery plan
Patel looked for local exercise programs that recognized her patients’ needs and challenges. Finding none, she created her own. Patients started getting in shape. Some were even able to be taken off blood pressure medications, medication for Parkinson’s disease and cholesterol medications, and to taper diabetes medications.
Eventually, Mary Ann Aldrich, RN, MS, clinical director for Community Care, at D-H, connected Patel to the YMCA Board of Trustees in Manchester, New Hampshire, which led to the development of a 12-week LIVESTRONG exercise program for all cancer patients in the Manchester area. Twelve patients allowed Patel to use their medical records to show how exercise led to health improvements in a grant application that secured an initial $50,000 from Anthem Blue Cross and Blue Shield of New Hampshire. More than 300 patients have already benefitted from the Live Strong program.
Rakis-Lambroulis is one of them. “After chemo, my body was in shock,” Rakis-Lambroulis says. “The YMCA program gave me a kick-start. On top of the exercise, I found a lot of camaraderie and made good friends. Cancer is hard on your self-esteem. Going to the Y, knowing I’d be with other people like me, was a boost. I felt a lot better.”
Cancer recovery takes more than 12 weeks, though, and Patel was looking for other exercise opportunities to offer patients. She found one through Richard Mullen, a patient’s fiancé. “I went to every one of my fiancée’s doctor’s appointments and chemotherapy sessions,” says Mullen, who owns and operates American Dragon Karate, in Hooksett, New Hampshire. “I didn’t know anything about cancer, but learned about neuropathy and lymphedema and thought, ‘We can fix some of that through karate movements.’”
“Mr. Mullen has spent so much time learning about cancer recovery and the muscles involved,” says Patel. “I’ve sent him information and see him using it in classes, some of which I have attended with my patients. It’s been an amazing collaboration.”
Weekly classes are typically attended by patients who are six to eight weeks out from surgery, though some patients start right after surgery. Patel has seen so much improvement, she has begun sending patients pre-surgery. “We understand everyone’s scenario, and make them feel comfortable,” says Mullen. “We do stretching exercises and can add weight to give an extra stretch. Tapping bags with the bottoms of feet or flexing toes and tapping with heels helps neuropathy. I change things up week-to-week so that the class is always interesting.”
Like the LIVESTRONG program, Mullen’s karate classes provide more than exercise. “People can talk to me and each other,” says Mullen. “We like it when participants bring a friend or family member. One woman brought her whole family. It’s great for our students to do something fun with their kids.”
Along with exercise, patients are reducing barriers to recovery and the risk of reoccurrence through nutrition. “By balancing proteins, carbohydrates, fats and starch, patients lose weight and balance their metabolism,” says Patel. “I encourage patients to use an app to get a gauge of what they’re eating. I use MyFitnessPal and share my diary so they can see my mistakes—I like my Reese’s Peanut Butter Cups—to make it more relatable.” Patel also accompanies patients on nutritionist-led tours of Hannaford Supermarkets (see page 6).
Addressing the need, understanding the benefits
The D-H Manchester Breast Cancer Program serves hundreds of patients, but there’s certainly room to grow. “My patients have told me, ‘You’ve done this for us, but we meet so many patients from other hospitals who don’t have these programs,’” says Patel, who would like to secure funding to expand karate classes, which she currently supports on her own.
“We need grants to help fund such programs,” says Patel. “Collaboration with Elliot Hospital, Hannaford’s, the YMCA, American Dragon Karate and other local resources and experts is yielding great results. I’d like to see more of it throughout the state.”
Patel also hopes to better understand why patients who take advantage of exercise and nutrition programs are doing so well. Recently named the American College of Surgeons State Chair for the Commission on Cancer, she has received interest in research from the University of New Hampshire, and would like to do a retrospective study of her patient outcomes.
“It’s unusual for a surgeon to take a broader view to patient care, but I also have a research background. I have learned that research isn’t any good if it’s not applied,” says Patel. “It’s frustrating when cancer returns and we wonder if we haven’t given patients all of the tools they need to succeed. It’s great when patients walk in to show me their blood work and say, ‘Look at this! What can I do next?'”