Lymph Nodes and Lymphoma

I don't usually write about stuff that's too "science-y." By that I mean the research that starts the process of trying to find a treatment. Sometimes I avoid it because it could be years before that research results in something useful (if it ever does). And sometimes it's because it's really hard to understand and trying to explain it would be difficult (for me and for you the reader).

But I read some Lymphoma research this morning that I think is fairly easy to explain, and which might actually be useful relatively soon.

A large group of researchers just published a piece in Nature Cancer called "Reprogramming of stroma-derived chemokine networks drives the loss of tissue organization in nodal B cell lymphoma."

The research is about the "architecture" of lymph nodes and how the nodes change with different types of Lymphoma. The researchers think that understanding those differences might help explain why some Lymphomas are slow-growing and some are fast-growing. And understanding those difference could lead to new treatments.

First some background. I think we all know what lymph nodes are. Many of us (though not all of us) became very familiar with them because they swelled up before we were diagnosed. And now every time we have any kind of bump or lump on our bodies we run to google to find out if there are lymph nodes in that part of our body. Lymph nodes are part of the immune system. They filter out bad things and help fight infections because they contain immune cells. When they are working well, they swell up. When they aren't working well, they stay swollen because there are too many immune cells -- a blood cancer.

The folks who did this research looked at the "architecture" of lymph nodes -- how they are divided up inside. Architects often design buildings with lots of apartments, so imagine a lymph node in that way. It's one structure with lots of apartments, and each apartment has its own separate family. So one apartment contains some B cells, a type of immune cell that is often called out first when there is an infection. (As you probably know, Follicular Lymphoma is a cancer of the B cells.) Another apartment contains some T cells. There are a bunch of different types of T cells, and they generally get called into action when the infection gets a little more serious. 

Now imagine there is a manager for this apartment building, someone who keeps the peace and make sure everyone is getting along. In the lymph nodes, this is what is called a Stromal Cell. These cells have a bunch of different jobs, but in the lymph nodes, they help keep everyone happy. They know that the B cell family in apartment 2A doesn't get along with the T cell family in 3B, so the Stromal cell makes sure they don't leave the apartment at the same time. When things are working well, this situation works out fine. The cells all get along, there's no cancer, and when there is an infection, the right apartment gets called on to do their job.

What the researchers found was that this same situation also happens when there is a slow-growing, indolent cancer like Follicular Lymphoma. The B Cells might have a bigger apartment in FL, but the architecture pretty much holds. Everyone does their job.

But when the cancer turns more aggressive, like with Diffuse Large B Cell Lymphoma, those walls don't hold. The Stromal Cells can't keep everyone in their apartment at the same time. It seems like that is where the problem begins. Imagine the apartment manager doesn't show up for work one day, or maybe had a few too many drinks the night before. He can't control all the cells in their separate apartments. 

What happens from there is a "vicious cycle." As T cells are called into action, they release pro-inflamatory signals. Basically, they start ringing the doorbells of other T cells and asking them to come out and play. And then those T cells start ringing the door bells of other T cells. Not only do they all come out and play, some of them stay inside and start knocking down the walls of the separate apartments. When this happens, it usually results in an aggressive Lymphoma like DLBCL. 

Wat the researchers found that is so important is that first, it's a problem with the Stromal Cell that seems to cause the bigger problems. And second, this loss of architecture isn't a result of the problem, it's the cause of the problem. 

My explanation is, of course, an oversimplification. The lymph nodes don't have actual walls dividing things. It's more like spaces where different cells hang out. But the comparison works -- when the apartment manager doesn't do its job, the building is a mess.     

Because the researchers seem to have targeted one cause of all of this, the Stromal cells, they are hoping that they can use that information to more accurately diagnose a patient, and then potentially find a treatment that targets the Stromal cell or some other part of the process that leads to the problem. 

It's very early research. It could be years before anything comes of it, if it ever happens at all.

But it's one more small piece of the puzzle that is Follicular Lymphoma. And that's something to be hopeful about.

Surviving in the Grand Canyon

I'm back!

You probably didn't even know I was gone, but I'm back from a week in Arizona, about 2500 miles from my home. My wife and I spent a week in Sedona, the Verde Valley, and the Grand Canyon. 

Anyone who has been to the Grand Canyon will tell you that words can't describe it and pictures can't capture it. But I'm going to give you a picture and share some thoughts anyway.

 

My wife and I had actually planned a trip to the Grand Canyon almost 30 years ago. I was going to Phoenix for work, and we had hoped to both go and spend a day or two at the Canyon. My wife was pregnant at the time with our oldest, and about a month before the trip, the doctor put her on bed rest because of a complication. Not only no travel, but no getting out of bed for more than a couple of minutes at a time. It was a very stressful few months. But mom and baby stayed healthy, and we had a beautiful baby boy. 

So now, almost 30 years later, we had the chance to try again, and we took that opportunity. We traveled with a group called Road Scholar. They aren't sponsoring the blog or anything, but I'm going to mention them because we've enjoyed our trips with them. They handle the details and make it easy for us to travel. We're at a point in our lives where we are happy to let someone else book our hotels, plan our meals, and do the driving. We just show up and enjoy ourselves.

As I said, words can't really describe something like the Grand Canyon, considered one of the seven natural wonders of the world.  And really, the details don't matter. But I will say that my wife and I spent a small amount of time on the Bright Angel Trail that goes down into the Canyon. We didn't go far -- less than a mile of the 16 mile trail. It was very hot and we were feeling the thin air. But we'd learned that less than 1% of the people who visit the Grand Canyon ever go below the rim. We felt like we had to have that experience.

Even going just a few hundred yards down the trail gives you a completely different perspective. You see things that you can't see from the rim. Your view is completely different. You become a part of something that 99% of the people around you are not a part of.

And for me, that's an important part of being a Cancer Survivor. 

My wife and I are getting older. And with age comes the usual slowing down. One or the other of us seem to have a new doctor or a new medication or a new diagnosis every six months or so. We're still reasonably healthy.  But we know that can change. We want to experience some things now while we can. For us, that means making travel a priority.

I mentioned the 30 year delay in seeing the Grand Canyon for a reason. I think lots of us put off doing things that we'd always wanted to do. For us, life got in the way. We had three kids, and dealt with everything that comes with having kids. They tend to take up your time, and your priorities change. And that's fine.

But then cancer comes along, and priorities shift again. There are so many more "what if" thoughts that come into our heads. Sure, I'd like to travel , but what if I pay for this trip to [insert your dream trip here] and the Follicular Lymphoma comes back? What if I feel awful while I'm traveling? What if I'm so worried about it all that I can't really enjoy myself?

We got tired of the "what if" thoughts and decided to just go with it anyway. There's always a "what if." We can't let that get in the way. Because there's one thing even worse that feeling unwell on a trip. It's looking back in 10 years and saying "I wish we would have done it anyway." If the Lymphoma isn't going to go away, we just pack it in the carry-on bag with the sunscreen and the granola bars. There's no sense in sitting at home staring at each other -- me, my wife, and the disease. It's coming with us. But we're all going.

Because that's what Survivorship is all about -- deciding how you will live your life after the diagnosis. 

You are the one who decides.

For us, we have decided that there's too much of the world we haven't seen, and we want to see it while we can.

Maybe you're not able to see the Grand Canyon, for whatever reason. You can't walk down from the rim and get a new perspective on the world. 

But I'll bet there's plenty of the world you haven't seen that's already all around you.

My wife tells the story of living just outside Washington DC. One year when she was in her 20s, her brother had returned home and the two of them went for a walk in downtown DC. They were walking near the Washington Monument when they realized that neither of them had ever been to the top of the monument in their whole lives, despite living 10 miles away. So they want to the top, and they saw the beautiful views of their hometown.

They didn't travel 2500 miles to do it. They traveled 10. And they changed their perspective and saw the world in a new way.

That's Survivorship. It doesn't have to take a lot.

I hope you'll do something fun today, maybe something you've put off for a while. I hope you'll do something to change your perspective on the world and your life. If you are able, I hope you'll start planning that trip you always wanted to take. 

You are the one who decides what your life will be after diagnosis. Don't worry about the disease. Bring it with you and have a great time. 

 

FLF Webinar on Health Data

The Follicular Lymphoma Foundation's next webinar will be "Your Health Data: How It Powers Research." It will happen on Friday, March 27, at 7am PT / 10am ET / 3pm UK / 11pm UTC. 

As with all of the FLF webinars, this one will feature a Lymphoma expert and a patient or caregiver. The expert is Dr. Peter Martin from New York Universioty Langone's Perlmutter Cancer Center in New York City. He is active with a group that promotes clinical trials for Lymphoma. The caregiver is Cris Carrigan, whose wife was diagnosed with breast cancer. He also has a professional background in cancer data. He is involved with a charity in the UK called  Use MY Data, made up patients, relatives, and caregivers who encourage cancer patients to allow their data to be used for research.

Use MY Data is an interesting organization. They don't hold any patient data. They encourage patients to allow their data to be used in clinical trials and other research. I don't know of any similar organization in the US.

The fact that such an organization even exists says something important.

I completely understand patients' reluctance to share their data. We live in a world where our data of all kinds -- financial, personal, medical -- is in danger of being stolen or shared. And we want to keep it close. Like I said, I understand. I've been given opportunities to work on certain projects that seemed interesting, but then I was told my medical records would need to be accessed. I backed away. I'm happy to share information if I have a good sense that it's going to help others (that's the whole point of this blog, after all).  But I'm crazy about the idea of giving unrestricted access to my electronic health records, especially if I'm not getting clear answers about how it will be used.

But that doesn't mean I would never share it under the right circumstances. If there was data that I thought would be helpful in finding a cure or helping other patients, I'd absolutely share it.

Think about it. If there were a large database of patient information that could be accessed by researchers that could help them better understand Follicular Lymphoma, wouldn't that be great?

That's where a group like Use MY Data comes in. Their mission is to encourage data use, but also to promote responsible and accountable use. 

Still skeptical? Understandable.

Then attend the webinar and see what they have to say.  And if you can't attend live, remember that recordings of all if their webinars are available later on.

I think it's going to be a very interesting session. 

No More Tazemetostat

The news came out this week that the makers of Tazemetostat will no longer offer this treatment to patients, including patients with Follicular Lymphoma. There are too many concerns about patients developing new, different cancers.

They made an announcement about a month ago that they were stopping a clinical trial that was testing it, and now they have decided to just pull it from the market completely.  

Tazemetostat is an EZH2 inhibitor. It works by inhibiting or stopping an enzyme called EZH2, or Enhancer of Zeste Homolog 2." This enzyme is controlled by the EZH2 gene. EZH2 keeps tumors growing, so when it's not doing its job, it needs to be inhibited -- stopped by Tazemetostat. About 20% of FL patients have an issue with their EZH2, though it can also be effective on patients that don't have that particular mutation.  

Tazemetostat was approved by the FDA in 2020 based on its ability to help that 20% of FL patients -- it was the first treatment that successfully helped that group of patients. The FDA approval was accelerated, meaning it was approved based on a small phase 2 clinical trial, rather than the usual, larger phase 3 trial. The accelerated approval, as always, is based on continuing research. A larger phase 3 confirmatory trial must be run to make sure the treatment is as effective and as safe as the smaller trial suggested.

Accelerated approval can be great. But sometimes the phase 3 trial that comes after approval shows some problems. And in this case, that problem was that the treatment may be causing secondary cancers. I haven't seen anything about how many patients developed the new cancers, or what kind of cancers. 

If you're wondering what happens to the patients in a cancelled trial: in this case, they will continue to receive treatment. The trial (called SYMPHONY-1) involved 2 groups. One received R-Squared (Rituxan and Revlimid) + Tazemetostat, and the other received just R-Squared. So patients who were enrolled in the trial will all continue to receive R-Squared. They won't be left without treatment. 

I have mixed feelings about accelerated approvals. They make new treatments available to patients who might need them. But they also risky in that they haven't gone through the full process that other treatments have gone through. On the other hand, even if there had been a phase 3 trial, the patients who volunteered for it would still be dealing with the same risks. It's all very complicated.  

The unfortunate part for all of us is that we have one less treatment available to us. And for those with the EZH2 mutation, that's even more unfortunate.  

But we can stay hopeful. There are lots of treatments available to us, and many more potential treatments on the way. 

 

 

More on the 15 Year CHOP Follow-Up

As I wrote in my last post, I have been looking for commentary from Lymphoma experts on the 15 year follow-up of FL patients who received CHOP. The researchers are suggesting that 42% of patients in the study were cured. I've been looking at Twitter/X, where there is usually a decent amount of commentary about Lymphoma, as well as in all of the google alerts I usually get.

There really hasn't been a whole lot of commentary. Most of what I have seen has been repeating the results of the study, rather than giving an opinion on it. One of the very few comments I have seen came from Dr. Mitchell Smith, the Chief Medical Officer for the Follicular Lymphoma Foundation. In a Facebook post from the FLF, he was quoted as saying:

"These findings are encouraging and confirm that some patients have very long-term remission after treatment. The challenge remains that we cannot yet predict which patients will be in this group. Follicular lymphoma is a complex cancer, and many patients live with the disease for many years with different treatment approaches. Studies like this help us better understand long-term outcomes while reinforcing the importance of continued research."​

 

The response is measured. It is positive and recognizes the importance of the research, but also makes it clear that there is more work to be done. The more I think about the study, the more this reaction makes sense. We've always known that some treatments give some patients very long remissions, not just CHOP. As I mentioned in the comments last week, I know a few people who have had RIT and are still in remission over 20 years later. That can be true for Stem Cell Transplants as well. And while I have never technically been in remission (I've never had a completely clear scan), I've been living with the disease for 16 years without needing another treatment, after I had six rounds of Rituxan. 

 

What's different here is that this research looks closely at a group of people who received the same treatment. A story about one person in remission is an anecdote, not a research study. This research is large enough, long enough, and rigorous enough, to have its authors dare to use the word "cure." But there is still work to be done, as Dr. Smith says.

 

Overall, I'd say there is reason to celebrate, but not to rest. It reminds me a little of the scene from the movie Elf (one of my family's favorites). Santa returns from delivering toys and says to the elves "We had another successful year!" The elves cheer, and Santa says, "And now it's time to start getting ready for next year!" The elves immediately go back to work. Worth celebrating, but there's work to be done.

 

********** 

 

Speaking of the Follicular Lymphoma Foundation, they have started a new series on their blog called "Science Simplified." In a series of posts, they will discuss some current research in FL in ways that make it easy to understand. Their latest is called "Who Needs Treatment and When?" It discusses some of the research at this year's ASH conference, focusing on GELF criteria. GELF is a French group, Group d'Etude des Lymphomes Folliculaires. In 1997, they proposed a set of criteria for when FL needs to be treated, and when a patient can watch and wait. The FLF blog post discusses an ASH presentation that examines the GELF criteria and how doctors make decisions about when to begin treatment. 

 

You Cancer Nerds will enjoy reading about research. And the rest of you (especially those of you who are watching and waiting) might enjoy reading about the practical implications of the research. 

 

More to come soon. Thanks for reading. 

R-CHOP 15 Year Follow-Up: A Cure for FL?

The big news in the world of Follicular Lymphoma this week is an article in JAMA Oncology describing results of a 15 year follow-up of FL patients who received R-CHOP (or CHOP + Radioimmunotherapy). The study suggests that 42% of the patients in the cohort have been cured of their FL. It's a big deal because it's really the first time anyone had seriously suggested that FL might be curable.

There's a lot going on in this study. It's worth looking into a little further.

The article is called "Treatment of Follicular Lymphoma With CHOP and Anti-CD20 Therapy: 15-Year Follow-Up of the SWOG S0016 Trial." The goal of this analysis was to see how many of the patients in the trial were cured after 15 years. They determined which patients were cured by a statistical method called "cure modeling," which provides an estimate of how many patients were cured.

I think that's important to note here. Part of the problem with determining whether someone is cured has been the nature of FL. With many other cancers (as I'm sure you are aware), if a patient is disease free after 5 years, they are often considered cured. That's harder with FL, since some patients will have the disease return after 6 years, or 10 years, or 15 years. So it's risky to say someone has been "cured" of their FL. 

And it's why many FL experts use the term "functional cure" instead. Someone can be diagnosed at 65, get a Complete Response, and never need treatment again, and die of something unrelated at 85 years old. Were they "cured"? It's hard to say. But they lived a life as if they were cured -- it was a "functional cure."

So this study defined "cure" using statistical methods because it's really difficult to say whether or not someone was cured the way they could for patient with something like colon cancer.

I won't pretend to understand the statistical analysis of the cure modeling, but I will say that since the article was peer-reviewed, it would have been approved by other experts in statistics before it was published, so I don't have any doubts about the analysis.

The SWOG study itself involved 531 patients. They received either R-CHOP or CHOP-RIT between May 2001 and October 2008. I don't write about CHOP much these days, so a reminder: CHOP is a traditional chemotherapy made up of four components (Cyclophosphamide, Hydroxydaunorubicin/doxorubicin, Oncovin, and Prednisone). It's been around for a while, and it's still a very popular treatment. R-CHOP is CHOP combined with Rituxan (rituximab/mabthera). When R was added to CHOP about 30 years ago, it increased its effectiveness. It's pretty standard now to include R with CHOP. RIT, RadioImmunoTherapy, is a treatment like Zevalin. It's essentially something like Rituxan, which can find the CD20 protein on a Lymphoma cell, but with a tiny bit of radiation attached to it, so the radiation can be delivered directly to the cancer cell. 

So of the 531 patients in the study, 267 received R-CHOP and 264 received CHOP-RIT. The 15 year Overall Survival rate was 70%, about the same for each of the two groups, though the RIT group had a better 15 year Progression Free Survival (the cancer didn't come back for 15 years for 47% of the CHOP-RIT patients, versus 34% of the R-CHOP patients). 

The cure modeling estimated that 42% of the patients in the study had been cured. The highest cure rates were in patients with low FLIPI scores and normal β2 microglobulin levels, essentially the patients with the lowest risk. (You can read more about FLIPI levels here, but keep in mind that it doesn't say anything about you as an individual, even though it seems like it does.) This isn't a surprise, really -- we expect less aggressive version of FL to be less problematic and more successful with treatment.

One important finding of the study was that the rate of relapse declined over time. For the first 5 years after treatment, 6.8% of patients in the study relapsed. But between years 15 and 20, just 0.6% of patients relapsed. So the longer the patients went in the study without relapsing, the less likely it was that their disease would come back. 

That's really important. Think back to the idea of "functional cure." It's hard to say someone is "cured" because the disease might come back after 10 or 15 years. But this study shows that it's much less likely to happen, so someone can be more confident after 15 years that the "functional cure" is an actual cure.

Te conclusion to all of this from the researchers is that maybe FL isn't incurable after all. The call this a "paradigm shift" -- a complete change in the way we think and thus the way we act. It could mean that doctors have very different conversations with patients, and that maybe R-CHOP is presented as a possibility for someone who might want a cure. It also has implications for future research.

***************

As I said, there's a lot happening here. This article was published about 4 days ago, and I've been waiting to hear what other FL experts have to say. So far, I haven't seen or heard much, but I think everyone is trying to take some time and digest it all. Paradigm shifts don't happen in 4 days -- they take years for everyone to break out of the way they have been thinking for so long (at least according to Thomas Kuhn).   

And I absolutely understand that. We (meaning much of the Lymphoma community) get so locked in to the idea that "newer is better" -- that every new CAR-T or bispecific or inhibitor must be an improvement over chemotherapy -- that's it hard to see a study like this and not be skeptical. It's certainly my own reaction to it, and I immediately start with a long list of "Yes, but" statements. "Yes, but it's just a statistical estimate, not an actual look at the patients." Or "Yes, but 42% is hardly a cure for all of us." Or, "Yes, but it's still a fairly small number of patients in the study, compared to the thousands that are diagnosed every year."

Particularly for me as a patient who was diagnosed 18 years ago, and who has been told this is incurable for all of that time, it's pretty tough to suddenly think otherwise, and even tougher to think the cure might be from chemotherapy.

That's why I'm especially impressed with the statement from Dr. Jonathan Friedberg from the University of Rochester Wilmot Cancer Institute. He was one of the authors of the study, and he's the one who is talking about paradigm shift (see the story that came out of the Fred Hutch cancer center where he is quoted). He's a Lymphoma Rock Star, doing cutting edge research on FL, and he's willing to look at the data and say "Maybe it's chemotherapy after all." 

The few comments from Lymphoma specialists that I have seen have been positive. It's clear that no one expects R-CHOP to suddenly replace bispecifics and CAR-T. But it could mean that conversations with patients are different. For some patients with low risk disease, and who are otherwise healthy and can tolerate the side effects, maybe R-CHOP is an option. CHOP contains an anthracycline, a type of drug that can be very effective but can also cause long-term heart issues. That kind of factor will need to be taken into consideration. 

I saw one commentor who said this study will have an effect on future research in a couple of ways. First, long-term studies of FL treatments will be measured against this. It's really interesting that this come out just after a 15 year follow-up of R-Squared. It's a much smaller study -- only 79 patients. But could the same cure analysis be applied to it? Could it be applied to a larger study of 500+ patients? If it was, could we make a direct comparison between the two treatments? It will be hard to look at any long-term study of an FL treatment now and think "Yeah, but....does it have a better cure rate than 42%?"

Another way this might change research is that there might be a greater emphasis on second-line treatments. That emphasis already exists, in some ways -- most new treatments get approved for relapsed/refractory disease first, and then as first-line treatments. But this cut back on the number of treatments that do that second step and get approval as a first-line treatment. In other words, we could possible have something closer to an agreement on how newly diagnosed patients are treated, and that treatment could be traditional chemotherapy. 

That's not to suggest that everyone will be getting chemo from now on. There are and will be lots of options out there, and more to come, for a long time. But I expect those conversations to happen.

I'm going to keep an eye open for more commentary about this. I expect some of the oncology websites to have videos of experts discussing this. I'm hoping for more debate-style videos, with multiple experts arguing for and against using R-CHOP. They would be more enlightening to me.

But I think the main take away for all of us should be the same thing. For at least some FL patients, a cure may be possible. For the first time, people seem willing to say so. 

Exercise Recommendations for Cancer Survivors

I've seen two articles in the last couple of weeks that are focused on the importance of exercise for cancer survivors. As you probably know from reading, I have become more and more focused on the role of survivorship lately -- the things we do after diagnosis and treatment that can improve our Quality of Life. 

The articles about the importance of exercise has especially caught my eye for a few reasons. 

First of all, I've been in Physical Therapy for a knee problem for a few months. I've been strengthening my leg muscles to help stabilize my knee, and I'm remembering how much I used to enjoy those kinds of exercises. I don't go to the gym much these days, but the PT work is a lot like a gym workout.

Second, for the last few weeks, I've been attending a yoga class. I tried a Tai Chi class, which I was excited about, but I had to stop it because of my (unrelated) knee issue.  I'm enjoying the yoga class, which is called "Yoga for Healthy Aging." The movements are gentle, but it's still a workout, and the focus is on things like flexibility and balance that we all need as we age. I'm the youngest person in the class; one man introduced himself by saying "I've been doing yoga since I was 83 years old." How's that for inspiring?

Third, I spent two nights watching the Olympics. I love cheering for the "old" athletes -- anyone over 30. More inspiration to get up and move.

Because I like to move my body, and I find that I feel better when I do.

The first of the two articles I saw was the JAMA Network from last week, called "Leisure-Time Physical Activity and Cancer Mortality Among Cancer Survivors." This article reported on research that looked at six different large studies from the past. The studies each looked at survivors of bladder, endometrial, kidney, lung, oral cavity, ovarian, and rectal cancer. The participants in the studies completed surveys and had their leisure-time physical activity tracked 1976 through 1997. There were 17,141 cancer survivors in the combined studies.

The researchers found that even low amounts of moderate to vigorous physical activity resulted in lower risk of death from cancer for patients who had been diagnosed with bladder, endometrial, and lung cancer. Doubling the recommended amount of exercise was associated with lower risk of death from cancer for patients diagnosed with oral and rectal cancer. For some patients in the study, their risk of death from cancer improved when they exercised even if they were inactive before they diagnosed. 

Now, there are all kinds of reasons why this doesn't really prove anything for us. There were no blood cancer survivors at all in this study, and it took place many years ago. But it's one of many that show that movement can be beneficial for cancer survivors; the first words of the Introduction the study are "The role of physical activity (PA) in mitigating cancer risk is well recognized." 

At around the same time, I saw a article from last month from Cancer: Interdisciplinary International Journal of the American Cancer Society. It's called "Exercise recommendations for older adults living with and beyond cancer: A consensus statement by the Advancing Capacity to Integrate Exercise Into the Care of Older Cancer Survivors expert panel."

The idea behind this was that there are lots of recommendations for older folks to exercise, but none that take into account the unique needs of cancer survivors over 65. This article presents some guidelines for how that group of folks should consider exercising.

To be clear, it doesn't recommend specific exercises, which is kind of the point. It assumes a few things -- first, that some cancer survivors over 65 do not move as much as they should. Second, that they have specific needs as cancer survivors. And third, that everyone's situation will be a little different. That's important. My exercise needs aren't the same as yours.

So the guidelines are kind of general. They start with the idea that someone who is a recent survivor should get a full medical evaluation before they begin exercising, and should the be evaluated by someone who understands how to make sure someone can handle the exercise they might want to do. They recommend tests for things like mobility and balance -- things that can be affected by the side effects of the disease or by treatments. They also recommend that an expert help design an exercise program, make sure that it is being followed safely and correctly, and that behavioral support is also offered (because it's pretty easy to get discouraged when you start exercising and you can't do everything you wish you could).

The principle guiding all of this is that barriers and risks should be kept as low as possible. The program should be manageable and enjoyable, not creating more mental or physical problems than the person started with.This is ultimately about Quality of Life -- being able to do the things that you want to do. That can be a struggle for some of us, especially as we get older, and especially as we deal with the effects of cancer. 

So, to me, the personal message from all of this is to keep doing what I'm doing. My wife and I still walk about 2 miles every morning with our dog. I'm in physical therapy for my knee, not ignoring problems until they get worse. I wish I had enjoyed Tai Chi as much as I had hoped I would, but that's OK -- I'm trying yoga instead. And if this doesn't work out, I'll try to find something else. But I'll keep trying and keep looking.

As we get older, my wife and I seem to collect doctors. We have a new health condition or  new prescription every six months or so. But we also have goals, like continuing to travel. And so taking care of ourselves physically becomes very important to us. Quality of Life -- doing the things that we want to do. 

So wherever you are physically, I hope you'll take some inspiration from the Olympics and try to start moving more. (And take advice from your doctor first.) I had lots of inspiring Olympic role models from the U.S. to choose from, but I have to say, the most impressive to me was Johannes Høsflot Klæbo, the cross country skier from Norway. He won every cross country event, from a sprint of 1,585 meters (about one mile) to a 50 kilometer race (about 32 miles). At one point, he was running uphill on skis at a pace of a 6 minute mile. Just amazing to be that great in so many different ways.

Take your inspiration where you can. But keep moving forward.