You can't outrun cancer... or can you...

First there is more fun on the Oncology service to be had by all. Then we discuss a landmark trial assessing the benefit of exercise as adjunctive therapy for colon cancer.

Most pertinent articles:

Bozzetti F. Potential Benefits from Physical Exercise in Advanced Cancer Patients Undergoing Systemic Therapy? A Narrative Review of the Randomized Clinical Trials. Curr Oncol. 2024 Dec 1;31(12):7631-7646. 

Courneya KS, Vardy JL, O'Callaghan CJ, Gill S, Friedenreich CM, Wong RKS, Dhillon HM, Coyle V, Chua NS, Jonker DJ, Beale PJ, Haider K, Tang PA, Bonaventura T, Wong R, Lim HJ, Burge ME, Hubay S, Sanatani M, Campbell KL, Arthuso FZ, Turner J, Meyer RM, Brundage M, O'Brien P, Tu D, Booth CM; CHALLENGE Investigators. Structured Exercise after Adjuvant Chemotherapy for Colon Cancer. N Engl J Med. 2025 Jul 3;393(1):13-25. 

Feng Y, Feng X, Wan R, Luo Z, Qu L, Wang Q. Impact of exercise on cancer: mechanistic perspectives and new insights. Front Immunol. 2024 Sep 13;15:1474770. 

Zylstra J, Whyte GP, Beckmann K, Pate J, Santaolalla A, Gervais-Andre L, Russell B, Maisey N, Waters J, Tham G, Lagergren J, Green M, Kelly M, Baker C, Van Hemelrijck M, Goh V, Gossage J, Browning M, Davies A. Exercise prehabilitation during neoadjuvant chemotherapy may enhance tumour regression in oesophageal cancer: results from a prospective non-randomised trial. Br J Sports Med. 2022 Apr;56(7):402-409. 

Transcript

SPEAKER_00 0:15

Hello, hello, my friends. Welcome to another amazing episode of my podcast. As I record this, it is the end of March. The weather is brightening up, flies are invading my home through the dog door. Rose, the biter, is too scared to push it open, so it has been taped open with packing tape since I bought it. I think a squirrel may have gotten into the house a few nights ago given the cacophony of frantic barking and snarling, but it didn't get away before being decapitated, which I know because said squirrel head was deposited on the end of my bed. I felt like I was in a Scorsese film. I scoured the house for a decaying body but didn't find one. Hopefully I didn't just miss it. But anyway, March means match day, which recently passed, and I am super excited to meet the new interns in a few months. And March also means tree fort. I am planning to go to all of it. Very excited to see Toon Yards on opening night. I would be a lying liar if I said it wasn't bittersweet though. And don't forget March Madness. No, not basketball, just the endless string of delirious patients I've had to send back over to the hospital recently. I can tell that spring is in the air because never have so many of them taken their clothes off and rolled around on the floor naked, as nature intended it, so to speak. But pivoting to the much more depressing topic I'm focusing on today, cancer. Full disclosure, there will be more swearing than usual today, with some unbleeped F-words because I fucking hate cancer. I was walking down the hall at work the other day when I heard the distinctive voice of a patient I know pretty well, and I turned my head to say hello and was stopped in my tracks. All I could think was, uh. I wonder how you spell that. When I met him about a year and a half ago, he was a tall, jovial guy with a reasonable amount of girth and a very full beard, kind of like a mountain man. He'd just been diagnosed with multiple myeloma, but did well with rehab and went home. Eight months and a few hospital stays later, and he was back in our unit. Still big, but doughy and pale, hair starting to thin. It took him longer to rehab this time, but he did again return home. Three or four months after that, and he's waiting for an appointment outside of oncology clinic, and starting to get that death look shared by so many patients waiting for their appointments outside of oncology clinic. More pallor, more vacant, sagging. And then recently, he looked like he died twice, maybe three times, and then was resurrected, shoveled into a wheelchair, and forced to act like a living person. Only cancer can beat a person down like that. The patients I take care of with cancer go through more than any other patients I encounter. What other disease eats you from the inside and often has treatment that is worse than the disease? And patients with heart failure think diuretics are a bitch. I recognize that medical science is making advances with more targeted treatment, immunotherapy, and improved management of the side effects of traditional chemo, but I still think if I was over 65 and diagnosed with anything advanced, I would just call it a good run while it lasted and unceremoniously wave goodbye. Okay, well, I admit my opinion is biased and that my psyche has been forever tarnished by the time I spent on the required inpatient oncology rotation and residency. There were two services. One of them was for solid tumors. Those were patients actively on chemotherapy who needed to be hospitalized for one reason or another. Usually it was some horrible complication of their cancer or a patient with a new diagnosis of something weird and awful that you can't even find any info about on up to date. Spinal cord compression was a common occurrence. Unfortunately, getting the neurosurgery consult team to call us back was like trying to get a derm consult for cellulitis on a weekend. We once desperately needed neurosurgery for two of our patients, and the only way we got them to respond was by one of my co-residents asking them while they were seeing her in the ED for a subdural she sustained after getting hit by a skateboarder while biking to work. So near mortal wounding of one of the seniors was the price of entry. She said it was almost worth it to get our patients seen. So dedicated. She went into primary care. Obstetrix was also a pain in the ass to get a hold of. We had admitted a 32-year-old pregnant woman with AML and couldn't give her anything besides Tylenol unless we asked them first. One night she was severely constipated, and I spent all shift paging their on-call to see if we could just give Muralax. They never responded, and by the time midnight rolled around, I threw caution to the wind and I just ordered it anyway. I was pretty sure that if something went wrong, it would be because of the intravenous poison that was running in and not the poop juice. And the service was a constant stream of subspecialists of all flavors. Mostly infectious disease, urology, neurology. ENT was surprisingly responsive. We had a patient on an absurd amount of oxygen per high flow nasal cannula who must have had terrible allergic rhinitis at baseline because his nose copiously secreted, and those secretions would harden as high flow nasal cannula is a bit like a hairdryer. Every single day, ENT would come and remove the giant staghorn boogers that had accumulated over the prior 24 hours. Did you know there is no medical term for booger? We exhaustively searched for one to no avail. Every day on rounds, my intern would talk about problem number one, booger. We started calling it nasolith, just to mix it up, although that is not an accepted technical term or an ICD-10 code. Another time I was covering that service, we had a patient with advanced squamous cell carcinoma of the penis, and he was there for complications related to his penis. So we said penis a lot. Penis, penis, penis, all day long. For a while we said penis instead. Again, just to mix it up. The other service was a liquid service. All the bad leukemias all the time. That service was even more miserable. Mostly older patients with AML coming in for their induction chemo. At that time, the survival curve for patients over 65 with AML was abysmal, though that might have changed with some new targeted therapies. But at that time, it was confusing to me that we didn't just have a door on the eighth floor that opened onto a cliff. So instead of going into an actual hospital room, patients would just funnel out the door over the cliff and on to a quicker, more humane end. There was also a fair amount of neutropenic fever after induction chemo, and then a lot of salvage therapy after the first chemo inevitably failed. If by some miracle things had gone well with the first chemo, they could potentially get a bone marrow transplant and then really go through hell. But that was a different unit of hell one floor below us. You could hear the screaming coming up through the floors when trying to catch a nap late at night. The worst was the folks who came in for a clinical trial, because they believed the treatment actually might make them better. Just like some folks think those supplements from their naturopaths will fix all their ailments. Both are about as likely, but in this case the naturopath wins because at least death by acute liver failure isn't painful. Those experimental drugs, the ones I encountered completely sucked. I never once saw any patient make it through a full course of whatever new treatment they were given. Mostly they would quit halfway through and beg to return home to die in peace, but usually by that time they were too sick to travel. So, oops, you get to die in a hospital room a thousand miles away from your family, but thank you for contributing to medical science. We did have some amazing attendings with perspective, who were rational and reasonable humans and excellent teachers. We also had some attendings who, while incredibly smart, were unflinchingly myopic in their focus on curing the disease without regard for anything else. One attending did a 15-minute teaching session one morning where he claimed that palliative care had no place in oncology, because what every patient wants is to have their cancer cured, whether they realize it or not. I'm still not sure if that was paternalism, misogyny, or narcissistic personality disorder. At least most of the solid tumor folks were at the end of a very long road with cancer that in the beginning hadn't been so bad. Rarely we would get someone who'd had a very recent onset of something catastrophic, and we were their last and only hope. Like Obi-Wan Kenobi, but with stethoscopes instead of lightsabers. In the close to eight weeks I spent on the service total during residency, I never saw anyone in that situation get saved. They just came to us to die with a prettier view out the window. But the liquid tumors? Not many had been sick for very long, but they were in for a crash course in the medicalization of life. Sometimes we'd readmit them multiple times within the span of four weeks. There were some refreshing things about the service though. We never had to worry about QT intervals because the oncologist told us not to, despite piling on four antiemetics and an antifungal. If we had a cold, we could take the day off without feeling guilty, because our rhinovirus might actually kill all of our patients without functioning immune systems. This is why I did almost eight weeks on the service instead of the scheduled four, filling in for people with sniffles. We didn't have to feel guilty about bad outcomes because nothing we did for anyone really mattered in the long run. And we didn't worry too much about having to write good discharge summaries because mostly the patients just died, and at that point, meticulous details don't matter. Okay, it is probably critical that I stop for a moment and impress upon you all that I do not hate oncologists or oncology. I just hate cancer. Cancer can go fuck itself. To be fair, I often disagree with many oncologists, but I also often agree with many oncologists. Most of the stories I share are worst-case scenarios. You know why? Because best case andor uneventful scenarios are boring and forgettable. They don't stick with you. My husband had cancer and died from it. His oncologists were amazing, so it's just not fun or interesting to talk about them. What I do think is interesting to talk about with respect to cancer is exercise. I don't know why exercise hasn't been a much bigger part of cancer therapy in the past. Oncologists are obsessed with ECOG status and whether the patient can tolerate the chemo, though I think sometimes they treat based on wishful thinking. The inpatient cancer unit I was speaking of was big into folks getting out of bed and walking the huge loop of that wing, and they would put a paper cutout of a foot on the door for every mile you walked. As a proponent of good clean living, I loved that, but it also sometimes seemed like slave driving. Walk monkey! Because everyone simply must get their treatment. Go big or go home, as it were. Death is merely a challenge and not a stopping point. Well, unfortunately, I think we'll need to pause treatment for now, have them follow up with me in one month with a CBC, chem panel, and LFTs, and if their ecog improves, we'll start cycle three. But the patient's already dead, sir. But is the cancer?

Exercise and cancer, an evolution of ideas

SPEAKER_00 10:38

But seriously, the idea that exercise might actually be beneficial in cancer is fairly new. In the olden days, people thought patients with cancer and cancer survivors should be chained to a bed, unmoving, and in misery forevermore. This almost surprised me until I remembered a not so distant past of smoking in the doctor's lounge, three-week inpatient stays for everyone while cared for by starched white nurses wearing ridiculous origami hats and sensible heels, and sometimes not even telling the patient their true diagnosis because they're already dying. Why add more stress? I read some articles from as recently as the mid-90s that raised concerns about exercise causing excessive fatigue in patients with muscle wasting and cachexia. This thinking evolved into the early 2000s when there was a lot published about how exercise prevents cancer, but still not about benefit for patients with active cancer until even later. That exercise could be beneficial in the treatment of cancer was initially investigated in preclinical studies, that is, those completed in animal, cell, or tissue models, not in actual humans. Through this research, we learned about the importance of exercise for the vasculature, oxygen delivery, and the immune system in cancer biology. The vasculature in tumors often is shoddy, which I thought would be a good thing. Starve the little fuckers, right? But apparently it's a problem. Poor oxygen delivery creates a hypoxic environment, triggering production of hypoxia-inducible factor 1 alpha, which suppresses immune cell responses against tumors. Checkpoint inhibitors work because they do the opposite of that. And HIF-1 alpha also promotes invasion and metastasis. Well, shit. A good vascular network also is important for the immune cells to access the tumor and to deliver chemotherapeutic drugs. As with other places in the body, exercise stimulates angiogenesis in tumors. The subsequent increased levels of oxygen has been shown to boost the destruction of tumor cells by immune cells. Exercise also increases the number of immune cells critical to destroying cancer cells and reduces tumor growth by increasing levels of dopamine and activating anti-cancer signaling pathways like AMPK. Excellent! Amazing! Okay, let's do this in real people with real cancer, right? Well, first they had to do a crap ton of studies proving that exercise was safe and could just do basic things like improve physical function. A narrative review on the subject was published in 2024. Potential benefits from physical exercise in advanced cancer patients undergoing systemic therapy, a narrative review of the randomized clinical trials by Federico Bazzati, published in Current Oncology. A narrative review is a comprehensive but qualitative study of prior research. They discuss what has been published without doing any new additional data analyses. This review reported on 35 randomized controlled trials of exercise in patients with cancer. Trial size range from 15 to 151 patients, most with 25 to 65, so pretty small. About a third of the studies used strength training, a third used aerobic training, and a third used a combination of the two. The outcomes were sort of a snooze, mostly physical performance or quality of life, to prove that exercise wouldn't make the patients just immediately explode into bloody little pieces. Some of the studies showed improvement, some didn't. The quality varied a lot. Importantly, there consistently was a low risk of adverse events, and exercise was well tolerated. No one exploded, not even a little. Adherence did vary a lot across studies, like a lot. 70% to 8.7%, which may account for the mixed results. Expectedly, adherence was worse with home-based exercise regimens as opposed to group settings or otherwise supervised. Raise your hand if you have a gym membership you used twice and then never went

The first trial looking at exercise and cancer outcomes

SPEAKER_00 14:17

back. Shockingly, only one of the 35 studies looked at cancer outcomes. It was not a great study published in Not the Best Journal, possibly by folks who tried really hard but didn't know how to design and then adequately report a research study. Exercise prehabilitation during neoadjuvant chemotherapy may enhance tumor regression and esophageal cancer by Zilstra et al. This was a non-randomized controlled trial based out of London, England, involving 40 patients with a diagnosis of operable esophageal adenocarcinoma who were in the process of doing three cycles of neoadjuvant chemo. Neoadjuvant means the chemo was before the surgery. Subjects either participated in a structured exercise intervention or had usual care. They didn't randomize. You just got the intervention if you were at Cancer Center A and were in the control group if you were in Cancer Center B. So if folks knew which group they were going to be in at time of sign-up, I feel like it may have been two very different populations who volunteered. One had to be motivated to exercise, and the other just had to agree to sit on the couch. And the control group did have a higher baseline BMI, so just saying. They didn't control for any confounders like age and functional status, stating they weren't important, which isn't true at all because both of those things dictate response to treatment. The exercise program was moderate intensity aerobic and strength training, though I'm still not sure exactly how much exercise it was after reading the methods section twice and then again upside down and backward. The outcomes weren't well defined, but from what I could gather, they looked at tumor regression and staging, body composition, and levels of various cytokines. They briefly mentioned that they calculated a study sample size, but then didn't say how many patients they came up with or the parameters of a power analysis if that is in fact what they did. Well, a lackluster design begets lackluster results. The intervention group apparently was exercising more because they had an improved fat to muscle ratio, and they might have found better tumor regression in the intervention group compared to controls if they group them in a certain weird way, but it might have been a type 1 error, and I don't know if the study was powered to detect a difference anyway. A type 1 error is where if you run enough tests, you are bound to get a positive result in there somewhere just by chance. So if you were to ask me 20 times what is a number you are thinking of between 0 and 50, one of those times I might actually get it right. It doesn't mean I read your mind, it just means I was bound to get lucky at some point. Why do I even mention this paper? Well, because it was the best controlled trial, randomized or not, looking at exercise as an adjunctive therapy for cancer treatment I could find, which was a total WTF moment for me. And to impress upon you the importance and groundbreakingness, not a word, of the challenge trial, which was published in 2025.

The CHALLENGE trial

SPEAKER_00 17:01

Structured Exercise After Adjuvant Chemotherapy for Colon Cancer, published in the New England Journal in 2025 by Cornea et al. This was a randomized, unblinded, controlled trial at 55 sites, mostly across Canada and Australia, that looked at the effect of a structured exercise program for patients with colon cancer. All patients had undergone complete resection of stage 3 or high-risk stage 2 adenocarcinoma of the colon, and then completed adjuvant chemotherapy within two to six months prior to enrollment without evidence of early recurrence. So diagnosis, then surgery, then chemo, then a few months, then they started the trial. Although they had just finished treatment for cancer, this was a pretty functional group at baseline. Ecog of zero or one and able to walk at a casual pace for six minutes. Reasonable liver and renal function, and no dramatic cytopenias. So this sample did not include patients hanging out in bed and only able to do the bed-to-batroom shuffle a few times per day. It also did not include folks with really aggressive cancer with very early recurrence, but you also couldn't be too fit to be in the trial either. If you were already doing 150 minutes or more of moderate to vigorous exercise per week, you were excluded. The only other real exclusion was a history of other malignancies, although there were a few exceptions I'm not going to mention. And the challenge trial investigators recognized that some baseline characteristics could be associated with inherent differences in outcomes. BMI, disease stage, baseline function, trial center, yes, Silstra et al, these things do matter. So randomization occurred after stratifying by these characteristics to ensure equal proportions between the intervention and control groups. The control group wasn't given nothing. They were provided with health education promoting physical activity and healthy nutrition within 14 days of enrollment. The intervention group? Well, their intervention was what I can only describe as spectacular. They too received the health education, but then they embarked on a three-phase physical activity program that included physical exercise with supervised exercise sessions guided by a physical activity consultant, and behavioral support sessions to improve motivation and troubleshoot any issues with adherence. Sounds like they took a hint from that prior study with 8.7% adherence. The ultimate goal was to increase physical activity by 10 met hours per week above baseline to a maximum goal of 27. 10 MOurs would be 60 to 75 minutes of jogging, depending on your speed, or two hours of brisk walking. The paper indicated that 27 Met hours, the max, was the equivalent of one hour of jogging three times per week, or one hour of brisk walking seven times per week. The dose of exercise was chosen based on public health recommendations for exercise around the world. Although here in the US, we now just rely on ivermectin, colloidal silver, and beef tallow cleanses. And the study really focused on making exercise a habit for life. In quality improvement, we call that sustainability, because why not do something in a way that will stick with people? Otherwise, it's just a fun little experiment, but will you actually change anyone's life in the long run? The training sessions, as it were, addressed all aspects of exercise, like warmups and cooldowns, stretching, how to safely train with weights, the importance of cross-training, and other skills like goal setting, motivation, time management, and exercising in bad weather. And they focused a lot on troubleshooting any barriers to meeting exercise goals that might come up week to week. Because keep in mind, these folks were not gym rats. At baseline, they were getting less than the recommended weekly amount of exercise for all comers. They needed to create new habits, which is harder than breaking bad habits. I used to be a gym rat. I'm more of a gym gerbil now, but I do ride my Peloton like a motherfucker when I'm stressed. The primary outcome was simple, disease-free survival. And even though the study was unblinded, that is largely an objective outcome, so lowish risk of biasing the result. Disease-free survival was defined as the time from randomization until the first event occurred. This could include death or having cancer again in some capacity, whether recurrence of the prior colon cancer, a new primary colorectal cancer, or a second primary cancer. They also looked at a bunch of physical activity and fitness measurements, mostly to show that folks in the intervention group were doing the exercise and reaping the benefits. Things like amount of exercise done, cardiorespiratory fitness as assessed with the fancy treadmill protocol, waist and hip circumference, and physical function based on the senior's fitness test. This was a time-to-event trial and was originally powered to be able to detect a hazard ratio of 0.75 for disease-free survival for the intervention group compared to the control. A hazard ratio is how often an event occurs over time in one group compared to another. You could also call it the relative risk of one group compared to the other. So a hazard ratio of 0.75 means there is a 25% risk reduction in the intervention group relative to the risk seen in the control group at any point in time. The only issue with this trial was that there were fewer events and slower recruitment than expected. So they had to extend the trial. And update their power analysis accordingly. They changed their anticipated hazard ratio to 0.67, which would require a three-year survival of 82.5% in the intervention group compared to the expected 75% in the control group, requiring at least 200 primary outcome events to have occurred across groups. I guess I haven't mentioned what a power analysis is and why it's important. A power analysis helps you determine what sample size you need in your study to detect an effect. You will need to have some idea about your effect size, so what is the magnitude of the result going to be? If it's large, your sample can be smaller. If it's small, you need more participants. In a time-to-event trial like the challenge trial, you determine how many events you will need as opposed to the number of participants. Researchers usually can estimate the expected effect size based on prior related studies. If it's the first randomized control trial, then observational studies might help. You also need to determine how much of a risk you are willing to take that your result is a type 1 error, which is your significance level, or p-value. We usually set it at 0.05, which means that there is only a 5% chance that your result is due to chance. And then you consider how much power you want the study to have. The power is the probability that you will find a true difference if it exists. We use different terminology like rejecting the null hypothesis, but that just confuses the hell out of non-scientists. By convention, studies usually say they want 80% power to detect a true difference, which to me always seemed too low. I'm now seeing more and more studies use a 90% threshold. Higher power requires a larger sample and more events, though. Frankly, with all the research put out with unreproducible results, I am in favor of the more stringent threshold. This study did go with 80%, though. Ultimately, they recruited 889 patients, a huge number, 51% women, 90% with stage 3 disease, the rest high-risk stage 2. Roughly three-quarters had an ECOG of zero. Chemo regimens were similar between groups. At baseline, patients in both groups reported doing just over 11 MET hours per week of moderate to vigorous physical activity. Phase 1 ran from baseline to six months. Patients in the intervention group participated in 12 bi-weekly face-to-face behavioral sessions followed by supervised exercise. They could do an additional 12 supervised exercise sessions, but they weren't mandatory. The goal was to increase the activity level by 10 MET hours per week. Adherence to both behavioral and exercise interventions was about 80% in phase one. Average MET hours per work of activity increased by about 10 at six months, the goal. Interestingly, the health education group also increased their activity, but by about half that of the intervention group. Phase two ran from months six to twelve. It again involved 12 bi-weekly behavioral support sessions, face-to-face or by phone now, and 12 supervised exercise sessions were recommended but not required. Adherence in this phase was 68% for behavioral support and 54% for the recommended supervised exercise sessions. Although participation in the sessions dropped some, patients continued to exercise the same amount, possibly a little more than in the first phase, even. The health education group also exercised just a little more. The last phase ran from months 12 to 36. It included monthly behavioral support sessions, face-to-face or by phone, and recommended monthly supervised exercise sessions. Attendance at the behavioral sessions was 60 to 70% depending on the time frame, while attendance at the supervised exercise sessions dwindled over time from about 50% to 30%. Nevertheless, the amount of exercise done stayed relatively high. The health education group also continued to do the same amount of physical activity. Across all time points, the intervention group had increased their activity by the goal of 10 Met hours per week, and the control group by an average of 6 Met hours per week. Cardiorespiratory fitness, the six-minute walk test, and physical function were better in the intervention group, indicating that this group was not only doing exercise but increasing their fitness. Body weight and waist circumference did not differ. There were 224 primary outcome events over the median follow-up time of 7.9 years. 131 in the education group and 93 in the exercise group, with a hazard ratio of 0.72. The primary outcome, that is death, or cancer again in some capacity, was thus 28% more likely to occur in the control group compared to the intervention group. There was a number needed to treat of 11.6 to prevent one event over the course of eight years. 107 patients died from any cause, 41 in the exercise group and 66 in the health education group. The hazard ratio of death was 0.63, meaning that you were 37% more likely to die in the control group. The vast majority of deaths were from cancer, meaning that you didn't live longer because the exercise improved your cardiovascular fitness. There were few adverse events attributable to the study. There were expectedly more musculoskeletal events in the exercise group, but not many were thought to be due to the exercise intervention. So what does all of this mean? Well, exercise absolutely can improve outcomes in stage 3 and high-risk stage 2 colon cancer. How big is this effect? Well, believe it or not, it is comparable to the effect of adjuvant chemo alone, as the hazard ratios for disease-free survival with chemo and with exercise are similar. Because all of the patients in this trial had already undergone adjuvant chemo, I can't say for sure that you would have the same benefit if you left out the chemo part, but if you do the chemo, you will get an additional equal in magnitude benefit by adding the exercise afterward. Another thing to consider is that the control group in this study also increased their physical activity. So the benefit may be even bigger if compared to a group who remained sedentary. Another thing to always think about is was there something else that might have been different between the intervention and control groups that could have accounted for the positive result? Randomization should eliminate any baseline differences, but sometimes it's a different part of the intervention that leads to benefit than we thought. In this study, weight was the same between groups, so that wasn't a factor. One thing that was different though was the intervention group had a lot of interaction and socializing with the team running the exercise program, and that very well may have played some role in the improved outcomes, just the socialization factor. I think the bottom line, though, is that the personal attention and exercise the intervention group received was very successful and should be replicated in studies of other types of cancer. Not just telling people to increase their activity, but the life-changing, habit-forming program laying out in a trial. It also should be covered by insurance companies because even a very involved exercise intervention is way cheaper than the overpriced chemo that might be prescribed after recurrence, with fewer side effects. Now, if you'll excuse me, I'm going to go ride my Peloton like a motherfucker. See you next time. Thank you.