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Zachary Klaassen: Hi, my name is Zach Klaassen, urologic oncologist at the Georgia Cancer Center in Augusta, Georgia. I’m delighted to have on again to UroToday, as always, Dr. Sarah Psutka, who is a great friend of the program. Today, we’re going to be discussing EAU 2025. She had a game-changer session in the plenary session talking about prehabilitation and the impact of exercise, personalized programs, and digital devices. Sarah, thanks again for joining us on UroToday.

Sarah Psutka: Hey, Zach. Good to see you. Thank you so much for having me.

Zachary Klaassen: Absolutely. So pull up some slides. I know you put some together—a summary of your talk at the EAU.

Sarah Psutka: Yeah. So this was really exciting. We had the opportunity to put together a plenary session on essentially all of the different supportive ways that we can think about improving the patient journey and the patient experience. And I had the opportunity to talk about some of the work that we’re doing on prehabilitation and the impact of exercise specifically. So this is just a summary of what we chatted about there.

But you and I have talked about this before. So what prehabilitation describes is basically this realm of interventions that are designed to improve functional capability in a patient. And the idea is that you do this before they undergo any kind of surgical procedure or medical treatment that essentially is meant to help them better withstand the treatment-associated functional decline or the physiologic insults.

And the whole goal here is that we identify modifiable risk factors, and then we really target those with supplemental or supportive care interventions, with the goal of helping that patient optimize their overall physiology. And the whole goal here, of course, is not only improved treatment tolerance, but then also accelerated recovery—so getting people back to where they started and helping them tolerate therapy better.

Exercise is something that I have always believed is extremely important for our patients. And as a lifelong athlete, I think it’s just important for all of us. But what’s really exciting is that in oncology, there is just increasingly robust data to support the myriad benefits that we see with exercise for our patients before, during, and after cancer care.

And so this is a summary from the ASCO guidelines that were put out regarding exercise, diet, and weight management during cancer treatment in 2022. Basically, the punchline is that the guidelines say that oncology providers should recommend aerobic and resistance exercise during active treatment—so during chemotherapy, in preparation for surgery—with the goal of mitigating side effects.

And they go through all of the domains that we can see benefits in, in terms of improving fatigue, helping patients sleep better, avoiding things like falls that can really be catastrophic in this vulnerable patient population, improving mental health, functional status. And, of course, benefits in terms of cardiovascular health and bone health.

And there have been international guidelines from Australia. We see European guidelines that are all supporting the potential benefits and sort of encouraging us, as oncology providers, to be thinking about how do we help our patients exercise more as they’re going through treatment to really sustain all of these benefits?

The issue is, in real life, this is actually something that seems to be kind of hard to do. And we see relatively limited uptake of exercise in our patients at this time. In surveys that have been done in contemporary populations, only about 7% of patients are meeting the guideline recommendations.

So the current recommendations are about 150 to 300 minutes of moderate activity per week for adults, and then two days of some sort of resistance training. Now, I’ll tell you, I would say that in general, in many populations, very few adults are meeting those recommendations. But we also see that over a third of patients who are adults with cancer actually are inactive, which means they’re essentially not doing any substantial activity whatsoever.

So the big question is, can we actually do this? Can we implement programs that help patients exercise before surgery, before cancer treatment? And do we actually see any benefit in doing so? The answer is there’s really emerging data that yes, we can do this.

This is on—this is an active surveillance prostate cancer trial that looked at men with low and intermediate-risk prostate cancer and demonstrated that when they were randomized to an intervention that was high-intensity interval training using running on a treadmill the patients did thrice weekly, we see benefits not only in key cardiopulmonary fitness measures, but interestingly, there were some interesting corollaries where we even saw some benefits in terms of improvements in biochemical parameters, such as their PSA level and their PSA velocity.

This was a recent review that our group put out of randomized controlled trials in bladder cancer. Basically, it demonstrated that among the bladder cancer trials that are out there, of 24 RCTs done over a 10-year period, there were 11 trials that looked specifically at exercise interventions, and 9 of them demonstrated statistically significant gains in the key objectives that they were hoping to affect, including benefits in these domains—so caregiver-related quality of life, patient-reported mental and physical quality of life, and then objective physical and functional performance measures and body comp in terms of improving muscle mass and reducing adiposity.

But this is a slide I think I’ve shared with you before, which is that some of the work we’ve done has also identified key early knowledge gaps in this field and some potential threats to the viability of prehabilitation interventions kind of writ large. These are the implementation barriers.

And a lot of the trials that have been done to date, there are some potential issues in terms of the likelihood that we’re going to be able to scale them, because they just take too many resources. They are mostly being done in gyms and observed settings, which both add to not only treatment burden and financial toxicity, but they just reduce the likelihood that we’re going to equitably be able to scale those across patient populations.

Zach, you and I both treat patient populations where a lot of folks are coming from pretty far to see us. This is a major issue. If we can’t get people to the intervention, we need to bring the intervention to the people.

And then, of course, the issue is also—I showed you a trial that was looking at high-intensity interval training. Well, I always say, I don’t need my bladder cancer patients to be able to flip tires. I need my patients to have what’s called functional mobility, which means they are independent and safe at home in their transfers between bed and rooms. They’re able to independently participate and complete their activities of daily living. After a major abdominal surgery, they’re able to safely transfer and can be feasibly discharged from hospital to home, where they can safely exist without major threat of, for example, a fall or not being able to—or basically risk of failure to thrive. And then pragmatism, of course, is super important in terms of personalization and safety.

So one of the projects that my group has recently become very involved in as we have been scaling one of our exercise interventions and implementing it in a current randomized controlled trial called the Get Moving trial—before we got that trial up and running, we actually undertook some qualitative research and interviewed a number of patients who had had radical cystectomies previously and asked them about what were the barriers that they perceived to them successfully engaging in pre-surgical exercise? And what did they think would help them exercise more? And we came up with a couple of key themes.

And these have been also—these are very much in line with what else has been written in the oncology literature in terms of barriers that cancer patients perceive to exercising and facilitators. And I just want to highlight a couple.

But really interestingly, key barriers that almost every patient brought up was the fact that they just didn’t get any instruction from their doctors about what exercises they should be doing, or even that exercises were something that they should be thinking about, that they were important. The visits were so focused on cancer care but didn’t really address this kind of supportive care sort of angle.

And so if you think about it, if you’re a doctor, these patients basically are telling us that they are listening very carefully to what the providers are saying. And if the providers are not encouraging or sort of suggesting that this is a key priority, then that will not be perceived as a priority by the patient. So that’s an opportunity for us, as providers, to really help facilitate uptake and implementation of exercise.

And then, obviously, access to facilities. And this is where, if it’s getting a patient to a gym in the middle of them also going through infusions for chemotherapy or also preparing for a major surgical intervention, that’s too much. We need to simplify sort of access issues, and that’s where home-based exercise becomes really interesting and important.

And then again, in terms of facilitators, it’s giving patients exercise type and guidance. And then, of course, creating opportunities for communication about the fact that this is really important. And then interesting—a lot of patients said when they had a health care visit coming up that they would exercise in advance because they knew they were going to get asked about it. So those are important.

So we’ve really, at Fred Hutch, started thinking about how to make this pragmatic and really tackling the implementation angle of prehab. Hanna Hunter, who’s a physical medicine and rehab doc, who I am fortunate enough to work with, and she leads our cancer prehab program here at the Hutch, she’s developed what she calls the Ps of prehab, which I think is just brilliant.

So she talks about making prehab personalized, pragmatic, making sure we prepare our patients, and then pacing them. And just as an overall quick highlight, whenever we give a prescription for a medication, we’re very detailed in what we tell patients that they need to do.

If we’re going to personalize exercise prescriptions, this starts with a functional assessment by someone who’s trained in exercise physiology, physical therapy, or physical medicine and rehab, where they’re really looking at potential vulnerabilities patients have in terms of their balance, their gait speed, their core strength, and their transfer safety.

And then they develop a prescription that is personalized to what that patient needs. We’re talking about exercises here that are really designed to help facilitate general conditioning, but also buttress vulnerability-specific strength impairments. And then we give a dosing and a sort of prescription—so how much they should be doing, the frequency, how many reps they should be doing. And then we also talk to them about potential side effects of something going wrong as they’re doing these exercises.

And then the pacing and the preparedness is really important. So fatigue is a major issue in cancer care. And one of the things that we talk about—a lot of the early prehab trials looked at using high-intensity interval training, which is really intensive cardiopulmonary exercise that gets your heart rate into that 80% of max or greater target. Now, that’s not going to be sustainable for somebody who’s dealing with severe cancer fatigue. So what Hanna talks about, and what we’ve started talking about, is this low-intensity interval training, which in a patient population that is otherwise vulnerable or has sort of lower cardiopulmonary reserve actually appears to achieve similar benefits in terms of improving cardiopulmonary fitness.

And the other thing is we’ve got to talk about stamina. So what we don’t want is this zigzag effect. We don’t want somebody to go out and walk three miles one day and then really take a hit and not be able to move for the next couple of days. We really want to affect slow, steady progress.

So conditioning exercises—we say they should be manageable on the best days and also the worst days—a day that you got chemo and you’re nauseated and not feeling great. We want to give patients exercises they can do even on those days, so that they basically can get a little bit of exercise every day and see that sort of sustained benefit.

And then the preparation piece is teaching patients how to do these exercises before they are going through the therapy, before they’ve had surgery, so that they know how to do them safely. They can do them. They’re prepared to do them. And then you basically—that allows them to more successfully do these exercises when they’re going through the stresses of cancer treatment.

And then I think one thing that we really are seeing is that there’s a lot of opportunities here to think about how we deliver these prescriptions better, and especially with expanding opportunities to utilize AI and also technology and smart devices. We can leverage technology to help patients access these interventions more equitably and in a more widespread, scalable fashion.

So AI is being used in multiple domains of prehab—not only to help us identify who needs them, candidate selection, but to actually facilitate the personalization of the delivery and the delivery itself. And then importantly, to monitor patients so that we don’t have to have them sitting in a gym with a bunch of exercise scientists watching them on the treadmill. But really, people can do this at home in a privacy-protecting way and not have to make further trips and add to their out-of-pocket financial burden of cancer care.

One key, I would say, argument I’ve heard against prehab repeatedly over the last couple of years as we’ve been talking about this is that it’s just not sustainable. It’s not pragmatic. It can’t work. Older adults are not tech savvy. They don’t have access to smart devices.

And what we know is that actually the older adult population is one of the most rapidly growing patient populations who are actively using smart technology and iPhones, iPads, and iOS devices—smartphones—and we see rapid uptake. So just between 2014 and 2017, we saw an over doubling of the number of patients who had an activity tracker—that’s like a Fitbit or an Apple Watch. And in 2021, over three quarters owned a smart device.

And when we surveyed our patients, basically 80% said that they would definitely be willing to use a fitness tracker if it was going to support their health. So I think that here, we see opportunities that are feasible in older patients and vulnerable patients to use technology to help deliver these prescriptions.

And so this was just the summary of everything we talked about. We talked about the fact that exercise is part of comprehensive cancer care. It can help get ready for surgery or chemotherapy. And it can be utilized throughout cancer care. And it’s actually recommended that we, as physicians who are caring for patients with cancer, integrate exercise recommendations in our care pathways throughout cancer care and survivorship.

But it’s got to be personal. It’s got to be pragmatic. We talk about teaching to the test. So if you know someone’s going to have abdominal surgery, you need to buttress core strength and balance so that they can safely recover, get out of bed after surgery, and be able to get home. We’re trying to accelerate recovery.

And then critically, when it comes to an implementation strategy, we want to think about how can we move this out of the lab, out of the exercise lab, out of the gym, out of the hospital, bring it home, make it privacy protecting? How can we help ensure that patients are doing this safely while they’re there in safety and the comfort of their own home? How can we make it cost-effective? And how can we modify it? And that’s a lot of the work that my group is working on right now with one of our current trials. So that’s everything. Happy to discuss.

Zachary Klaassen: Yeah. Awesome work as always, Sarah. I feel like I listened to your talk at EAU, I listened to your talk today, and I learn a little something every time we have this discussion. And I think there’s one thing that jumped out to me from today—this whole make it personal, this exercise prescription. I love that terminology. When you’ve used this in your practice, what specific group or groups of patients has this really worked well for?

Sarah Psutka: So here’s the thing. One of my sort of, I guess you could call it my hot take, is that I think prehab is for everyone. I don’t care if you are going through—if you’re getting ready to go through a major surgery, like a radical cystectomy in five weeks, or if you are coming to see me for a small renal mass or active surveillance for your prostate cancer—we, you and me, should be exercising every day. Our patients should be exercising every day.

And here’s the thing. I think that if you—this is the opportunity for improvement. It’s easier to do this when you feel good.

Zachary Klaassen: Yeah.

Sarah Psutka: Easier to set good habits when you’re not dealing with a major physiologic stress. So the patient population that you can maybe affect the most gains in is somebody who’s not actually sort of experiencing major toxicity from all the therapies that we’re giving them.

So I talk to everybody about exercise as just part of cancer care. And some of the biggest benefits—I’ll tell you one quick story. So I take care of a lot of older adults with nonmuscle invasive bladder cancer.

And I had a fellow who was 86 when I first met him. I’ve been taking care of him. He’s now 92. And he was using an assistive device. He was definitely expressing a lot of cognitive changes at home. His wife was worried. He’d been having some falls.

So years ago, I got him in to see our PM&R doc. And he started doing some exercises. He started going to a chair yoga program at the local Y. And he and his wife just made this part of their life.

Zachary Klaassen: Yeah.

Sarah Psutka: So he stopped using an assistive device. He goes to exercise classes three to four times a week. And then last year, he had a stroke—a really bad one. But what was amazing was he was only in rehab for a couple of weeks.

And his wife was like—they told him he was—he got out of rehab. He’s home again. He doesn’t have any, thank goodness, persistent neurologic deficits. But they said the reason he got out was because he had been exercising so much.

Zachary Klaassen: And he had the habit already before he even had the stroke.

Sarah Psutka: Yeah. So he was just—he was in the best shape he could have been in for an early 90-year-old. And he was able to recover and actually get back home after having a stroke. And so those are the folks who we think about affecting benefit.

And so we actually—I had mentioned to you before. We just got some good news in that we just got some new funding from the Andy Hill Care Foundation, and we’re going to start a new trial. So we have—our current trial is looking at personalized home-based exercise prescription delivered through a digital app called Exercise RX in patients getting ready for radical cystectomy and nephroureterectomy. So it’s any major, definitive surgery for muscle invasive or locally advanced urothelial cancer.

Our new trial is called the EMPOWER trial. And this is actually going to be for patients who are on maintenance therapy for their nonmuscle invasive bladder cancer. And we’re going to see if we can build this out into more of a survivorship population. Because I think that that’s a huge swath of our patients who are medically vulnerable—oftentimes have some pretty substantial physical impairments. And they are—but they have longevity ahead of them. So let’s make their lives better in the long run.

Zachary Klaassen: And some of those patients unfortunately may need a cystectomy. They’ve already got the skill set and the habits before they get ready for a big operation as well.

Sarah Psutka: 100%. And here’s the thing. A cancer diagnosis is a substantial teachable moment. That’s when we think about—this is when you talk about optimizing other medical conditions. It’s when you talk about quitting smoking. This is when you talk about decreasing alcohol use and quitting alcohol. So why not—we talk about all the quitting. Let’s talk about something that’s building—really positive.

Zachary Klaassen: Yeah. I love that. That’s great. My last question is just around that population. You mentioned a little bit in your presentation about the elderly, the rural, maybe that people have a flip phone versus a smartphone, or maybe they have a smartphone but don’t use it that much. How do we target them? And I think this home access and getting a setup at home or a program at home is maybe part of your answer. But how do you speak to those patients? Because again, like you said, those are a lot of my patients as well.

Sarah Psutka: Yeah. So I think that’s—our current trial, we are using a smartphone-based app that was developed by our folks here that link to our electronic health record. So what’s interesting is they go see our PM&R doc. They have one brief physical assessment that just looks for movement-related vulnerability, functional disability that we can target.

We have a menu of exercises that all have videoed instructions. The prescription is based on whatever functional impairments that our PM&R team identifies, and that evaluation can be done virtually. Because I don’t know about you—we are really using a ton of telehealth. And so our patients actually are getting pretty good at that.

Zachary Klaassen: Sure. Ours too.

Sarah Psutka: It’s something that I think in the post-COVID world, we’re all just obviously getting really good at using Zoom.

So it’s interesting. We are finding that these patients can really interact with this app pretty easily. And what they do is they just have to interact with it once a day. They pull it up, they turn it on, and it visually tracks them. So they see the model, who is one—the people who do the exercises in our videos are all patients who have had cancer and had a cystectomy. They are patient advocates who helped us build the trial.

But the patients also see an avatar of themselves in the corner, so it’s like a mirror. And so they can see themselves doing the movements. They can track what they’re doing and make sure it matches as the model is going through the reps.

On the back end, our engineering team has the video feed, which is privacy protecting. So we can track adherence, but we’re also testing because all of the smart devices have sonar capabilities. So repeated movements can be tracked with sonar. And that way, we could actually get away from the video feed, which will decrease the engineering costs of doing this, which is kind of cool.

Zachary Klaassen: Yeah.

Sarah Psutka: And then the neat thing is from—we also have to think about provider burden.

Zachary Klaassen: Yeah.

Sarah Psutka: If I have to check in, it would be like, did Mr. ____ do his exercise? Did Ms. White do her exercises? That’s too much. So we actually just have a big old dashboard that pops up where it says, is the patient doing 75% or more of their target or less?

And then we have auto pings that we can share with patients that are encouragement. And also, if somebody is falling off the pace pretty massively, then our team can reach out and make sure they’re OK. So it’s also sort of an early warning system for somebody who may be struggling medically.

And I think that overall, yes, we do run into some technological issues. And we have 37 of the 102 patients we need to enroll in our trial currently accrued. And we’ve had a couple of dropouts because of patients who are struggling with the tech. But that’s actually something we’re working on developing is trying to make it a little bit easier.

Zachary Klaassen: Yeah. No, that’s great. I think it’s always a fun conversation with you. Any last-second take-home messages for UroToday listeners?

Sarah Psutka: I guess if there’s one thing, just remember patients really listen to what you say. So if you tell them that exercise is important, they’re going to take that to heart. And that’s where—it is a lot that we have to counsel patients about in a really short amount of time.

But you can say, look, this is something you can do. This is—I talk to patients about taking a little bit of control and saying, this is something you can control right now that is super positive. If you can walk a little bit more every day—but you have to be a little—you can’t just say, walk more. You have to say—

Zachary Klaassen: The prescription.

Sarah Psutka: You’ve got to get a sense for what they’re doing. And then you can’t say—it’s not 10,000 steps for everybody. If they only walk 1,000 steps, they need to walk 1,050 steps.

So you say, what do you do right now, and give them a discrete goal. And then you make that goal a little bit more. So it’s a bit of extra work on our end. But I will tell you, patients feel so much better when they’re doing it. So—

Zachary Klaassen: Absolutely.

Sarah Psutka: Yeah.

Zachary Klaassen: Awesome job, Sarah. Great chatting with you. And thanks, as always, for your time on UroToday.

Sarah Psutka: It’s my pleasure. Thanks, Zach. Thank you to everybody—for your team for highlighting this work. I really appreciate it.

Zachary Klaassen: Our pleasure. Thank you.