How Exercise Professionals Can Transform Cancer Care | Kate Bolam on Leadership, Confidence & Clinical Impact

In this episode, we explore the future of exercise oncology, how research translates into policy and practice, and the expanding role of exercise physiologists in cancer care with expert Kate Bolam. Discover insights on developing guidelines, implementing community-based programs, and addressing health disparities.

Connect with Kate:

Kate Bolam Linkedin
Email: katherine.bolam@gmail.com

Extra resources:

Cancer Council Booklet

Checkout our range of courses: https://epcpd.com/

Transcript

SPEAKER_01 0:00

Welcome to the Successful EP, the podcast where we talk to leading exercise physiologists about building successful, impactful careers, running thriving businesses, and advancing the profession. I'm your host, Leonard Hazewood, founder and exercise physiologist at Adapt Movement Physiology and Growth Specialist at EPCPD. On this show, we dive into stories, strategies, and lessons from EPs and health professionals doing exceptional work and spark conversations that EPs should be having but often aren't. Today's guest is a leading voice in exercise oncology and cancer survivorship research with more than 20 years of experience as a clinical exercise physiologist and researcher improving outcomes for people diagnosed with cancer. Across her career, she has contributed to more than $23 million in research funding, collaborated with over 20 international partners, and worked across clinical practice, academia, research leadership, and health policy in Australia, Sweden, and Thailand. She currently leads the Swedish Cancer and Exercise Guideline Initiative and is part of the SWE Can Move Network, advancing exercise within cancer across Sweden. Her previous roles with the Baker Heart and Diabetes Institute and Karolineska Institute focused on translating exercise oncology research into real-world clinical practice and survivorship care. What makes her work especially impactful is the focus not only on what works, but how to make exercise accessible for people living with cancer across different healthcare settings and communities. In this episode, we explore the future of exercise oncology, how research is translated into policy and practice, and the expanding role exercise physiologists can play in cancer care moving forward. Kate Bollum, welcome on the podcast.

SPEAKER_03 1:38

Lovely to be here.

SPEAKER_01 1:40

Like we touched on before, uh, it was really awesome just to hear all the work that you're doing at the moment, particularly yeah, in Sweden, um, around developing some guidelines for um exercise oncology. Before we sort of delve into that though, I guess I've given a brief overview of your background, but did you mind sharing sort of, I guess just going back a little while now for you, uh, what your journey was initially going into exercise physiology and exercise oncology?

SPEAKER_03 2:07

I mean, most things in my life are quite serendipitous. Some sort of like a sliding doors moment happened, and before you know it, the sort of pathway of my life has taken a very sideways turn. And it's usually worked out great. So what happened was in high school, I think I chose two subjects. I think I chose music and something else. I don't remember now, but they clashed in the schedule. So I thought, okay, what should I do? And so I chose PE. And that was my first sliding door. I wasn't going to choose PE, senior PE, except that it just whatever I wanted to choose probably would have been a m maybe art. Um yeah, it just clashed. So I got into PE, senior PE, and I was just not great. I I'm not a coordinated soul. I'm not naturally sporty, I'm not naturally competitive. So, but but I could write a good assignment. I and I ended up actually topping PE, and I still don't know how, maybe because dance was in there and I like to dance too. But I started to realize that I I enjoyed that that aspect of that subject. And my PE teacher had done human movement at UQ. And so he suggested to me this might be a course that you might be into, which is uh human movement studies back in the day it was called. And so that's what I applied for after that sliding doors moment. And that's how I got into studying human moves movement studies back in 2001. It was. Yeah. And and still then I didn't think that I I didn't know that I wanted to work with people with chronic disease. I still had these fantasies of working with sports and athletes and to be a sports trainer. And so, you know, in those first few years, I was doing some praks with AFL teams, and I it almost seems like another world that I would have been interested in that back then. But uh but I was. And then at the same time, I was doing a bit of work experience with Tim Henwood and his PhD and in age fit is a a gym for people over 60. And in 2001, that was pretty novel. So at the same time, I had these two parallel lives that I was sort of dabbling in, you know, working with older adults and strength training in this gym, and then also the AFL players, and it would become very acutely clear to me which one I enjoyed. And so then I started veering towards older adults, chronic disease. And that's really also how I got into that field. Yeah. That's that's really I just loved working with older adults. I I found it creative. I have ADHD. So I think I found the creativity of having to adapt all the time when you have an older adult who maybe can't do exactly the exercise that you want to do. And I love chatting with them. I love all their wisdom. So, and that has been a thread, I think, throughout that I just love working with older adults. It's pure joy.

SPEAKER_01 5:13

Yeah, for sure. That that makes sense. I think I'm a little bit similar in the sense of um learning the wisdom sometimes from older adults. Like I feel like a lot of people underestimate um what the older generation, oh, they're slow, they have less energy, or why do I want to work with them? But a lot of the things that they say are life lessons that can then skip you forward literally five, 10, 15 years if you just know how to listen.

SPEAKER_03 5:41

Yeah. Yeah. And I I think for me, my brain really enjoyed seeing these huge differences, you know, in in athletes. I think you've got to be motivated by these minute but very important changes that you're searching for in the sports science world. But when I was seeing people who couldn't get out of a chair, you know, start doing these awesome, you know, PBs in their leg press, I I thought, okay, this is for me. I love this stuff. So that's that's where I went into that. And then I graduated and I I'd been an exchange student before I went into my undergraduate degree and exchange student in Thailand. And I still had that in my heart that I I wanted to go back to Thailand. So I then moved back to Bangkok after I graduated as an accredited exercise physiologist. And of course, I don't have exercise physiologists in Thailand, but I found this other Australian working there. And then I started working as an exercise physiologist personal trainer for those who were healthy for people living in Bangkok, mostly their expat community, but also some local Thai people. And I did that for the next three years until I realized that it was time to come home.

SPEAKER_01 6:57

What was what was the main difference that you noticed between delivering that service over in in Bangkok versus Australia at the time?

SPEAKER_03 7:06

It's completely unregulated. It's completely unregulated. So I had to really um work within what the, you know, the rules that I'd learnt in Australia. Um and I think that there was also just a complete lack of access to exercise physiology services for people in Thailand. So I had to do a lot of sort of education of of who I am, what I can do. And then people really appreciated it. But it was um, yeah, when you're the only exercise physiologist in the whole country, as far as I knew, then you sort of have to um do a bit of advocacy also.

SPEAKER_01 7:41

A little bit is probably putting it mildly.

SPEAKER_03 7:43

Yes. Yeah. But I can talk, so that's never been a problem.

SPEAKER_01 7:47

Yeah, of course. Do you mind me asking on that same note? Did you see more healthy population or more chronic disease and clinical population over there?

SPEAKER_03 7:55

Started off with healthy population. Once people realised the knowledge that I had, then their sort of, you know, their sisters and aunties and kids who had chronic diseases started coming to me. So yeah, it progressed more that way.

SPEAKER_01 8:10

Interesting. And do you feel like there is a as big a health burden um with chronic disease over in Bangkok as Australia?

SPEAKER_03 8:19

Yes. Yeah, absolutely. It's just harder to to reach people, I would say, without the established systems, then it's it's harder to reach people because I don't have like a chronic disease management plan, those sort of things. So it is a bit more word of mouth, but absolutely they do. Absolutely they do.

SPEAKER_01 8:37

Interesting. I guess fast forwarding towards exercise oncology, what sort of prompted you to dive down that avenue?

SPEAKER_03 8:46

The serendipitous moment. I'd read this great I'd read this great book. It's called The Brain That Changes Itself. Fantastic book. It's about rehabilitation and I recommend it to everyone. And so I started reading this book and I thought, you know, that's what I'm gonna do. I'd come back from Thailand and I thought I'm gonna do my PhD on maybe stroke rehabilitation, all of these type of things, the neuroplasticity. So I I walked in very confident, as you do, um, to um one of my old biomechanics professors at UQ, and I said, Look, I really want to do a PhD on neuroplasticity. And he said, Oh, look, Kate, your biomechanics marks weren't great. They weren't great. Um, and and they weren't. I was just very confident. But he said, if you go next door, Professor Dennis Tafe has just won a lot of funding for a study, NHMIC, prostate cancer and exercise trial. And so I did. Booked a meeting with Dennis and I went next door and he said, Yeah, we actually need a PhD student on this, and your expertise in in older adults would be perfect. So that's how I started my PhD. Again, like literally sliding doors moment. And I didn't know much about cancer then. We didn't have much or any, I I can't remember in our undergraduate degree back in the early 2000s. So I I learned a lot while I was in that first year of my PhD. And yeah, so I did my PhD on trying to understand the role of exercise for men who receive the um androgen deprivation therapy for prostate cancer, essentially deletes out the testosterone in their body. Very effective treatment, but also comes with a lot of side effects and and side effects that exercise has a lot of potential to improve. So I worked with these wonderful men. We had sessions, you know, four times a week, every week for a long time. It was a lot to ask of these men. Um, and they signed up. And so I worked with these men, you know, five hours a day for four years. So it was a it was a joy, those those men. Um, and that's how I got into it. I started, you know, in prostate cancer and and musculoskeletal health were the real outcomes. And this was back in 2009. So we we were starting to understand, you know, well and truly that exercise would help. But in Australia at least, uh it was sort of just beginning. And that was so that trial was with Rob Newton and Dennis Tafe and Daniel Garveyo and Prue Courmy. And so I was really learning from from that game early on, which was pretty, pretty grand.

SPEAKER_01 11:23

Rob's fantastic. We got him on the uh podcast as well. His um Yeah, his story is is really powerful as well.

SPEAKER_02 11:29

Yeah, yeah.

SPEAKER_01 11:30

So with the with the four four sessions you did per week uh for five hours, what what was the time period over which you monitored that?

SPEAKER_03 11:38

So they were asked to come in for a year.

SPEAKER_01 11:41

A year.

SPEAKER_03 11:41

It was yeah, it's a lot to ask. I mean, and this is what I always say, you know, this this is something that I've been thinking about lately, about how exercise physiologists in the real world, you know, a lens they can have on when they read our papers. So if we think practically, who are these people who, in the potentially worst time of their life, have had the capacity to say yes to coming in four times a week for an entire year. So they're the people who are in our study and they exist. Like they do exist. And sometimes sometimes it is the people who are most sick because they're they're almost desperate to to have something. So it's not that they're all have like a very good capacity, somewhat complete opposite, but I think it's a good lens to have as a person reading our papers that these are the people who are at that stage of readiness to I mean, w would I commit to that? Like, would you commit to that four times a week? I'm gonna come in four times a week for a year. Every week it's a lot. So anyway, that's just yeah.

SPEAKER_01 12:53

I've I've sorry to interrupt. Um, okay. I just got a question on that as well. What was the outcomes of the study?

SPEAKER_03 13:00

Yeah, so I looked at bone. I looked at bone density because we have, you know, it's just a rapid decline in BMD, bone, bone density for these men and muscle health. So that was but the paper, I mean, the study looked at all sorts of cardiovascular health, quality of life. There was quite a few outcomes. And so we looked, we did resistance training and impact loading. So we asked these men to do some pretty intense jumping actually for these for these weeks. So it was a it was a lot to ask for them. And I think in the end, we slowed down the bone loss, but we couldn't reverse it. It was just we had great like effects with muscle. I think the muscle was, you know, that was really great, which is, you know, not to be sneezed at. Like that's really great outcome. But for bone density, the losses that we're seeing are just incredible. Um and it it whatever we did, it just wasn't enough.

SPEAKER_01 13:54

I guess on that topic, I I do want to delve into this a little bit because I think this is really powerful. And but, you know, particularly being at your uh having having been involved in that directly, it's it's even more powerful. With um with the the bone density losses, were you was there measurements prior to the study that then indicated that during the study the rate did slow down?

SPEAKER_03 14:17

Yes. So they everyone got a DEXA. So we did DEXA at the hip and spine um at the beginning at baseline, and then again at nine months or twelve months. So yeah, it was a gold standard of of checking how it is. I mean, you could also look at a PQCT. So bone, you don't, you don't particularly with exercise, you there's lots of different ways that bone can become stronger. It can become stronger by just getting more. So in in terms of metabolism, you're encouraging bone more. But the bone can also become stronger by as it grows, it grows into a way that becomes stronger. So the shape becomes stronger, even if it necessarily doesn't put on extra bone. So there's two ways. And so DEXA can just say, you know, there became more bone, or uh, but a PQCT can tell us that, you know, whether the shape changed. Um, and that helped us. So we didn't have PQCT, just just DEXA.

SPEAKER_01 15:14

And with the muscle health side of things, so did you see, did you use like a how did you measure, how did you measure muscle?

SPEAKER_03 15:22

Uh we use a DEXA too, so the whole body DEXA, which was good. That was a good way to do it. But we also had um muscle strength tests like a 1 RM for the legs. Yeah.

SPEAKER_01 15:31

So yeah, exactly right.

SPEAKER_03 15:34

Yeah.

SPEAKER_01 15:35

Awesome. And so just to clarify as well, those uh muscle measures and strength measures seem to positively increase.

SPEAKER_03 15:41

Yes. Yeah. And I think that's that that that we uh that's one that we can be really sturdy with, I think, if when we're training people who have got cancer and we can get their muscle strength up. I think that's that's we can say that. Sometimes it's really hard to get muscle mass up for all sorts of reasons probably. But you know, ideally we'd like to get both up, but certainly we can get muscle strength up.

SPEAKER_01 16:04

And with the quality of life outcomes, I know you mentioned that you may not have been directly involved in that, but how did they um and gosh, I can't even remember, but I'm quite sure that they improved too, but I can't remember. So it's okay. It's got back a few number of years.

SPEAKER_03 16:19

Yeah, yeah, a lot. And I don't remember yesterday.

SPEAKER_01 16:22

Yeah. No, the main reason I'm asking on this particular topic is yeah, I'm thinking of uh, you know, my own clients, and I'm sure there'll be other EPs listening that are trying to, you know, relate this to their own clients and and sort of give evidence-based advice um around around this. And I think really good evidence-based advice is your understanding of the the person in front of you, the understanding of the the literature, and then I would also say um, you know, professional input from one of your colleagues, so similar to what we're sort of doing right now. Um so yeah, just getting that, you know, further certainty, I think, for a lot of EPs is is really reassuring.

SPEAKER_03 16:58

Yeah. And I think don't underestimate the things that we don't use as outcomes in research. So, like one of my favorite moments was we were working, you know, later on in Sweden and with women with advanced breast cancer. And one lady, I mean, there's a lot of boating in Sweden, they love boats. It's very much a sea life type country. And one lady had stopped going on her boat because she didn't have the balance and the muscle strength. And that was what was important to her. So at the end of the trial, she could get on her boat and she was sturdy. And so she sent me a photo of her on her boat, and she was sturdy, she felt safe, and she got the joy of being on her boat. And so we'll never record that in research. We'll never have like joy of being doing the things that you want to do or the things that are important to you. So I think, and this is what clinical exercise physiologists are excellent at translating those outcomes that we measure, the boring ones like muscle strength, into what matters to people. Um so I think don't underestimate those ones too, the ones that bring joy.

SPEAKER_01 18:08

No, absolutely.

SPEAKER_03 18:09

Yeah. And again, another thing that's not captured in our trials that EPs do so well is finding out what's important to the person. We don't really do that in our trials. And so, I mean, it's a whole nother tool in the tool shed to be able to find out what people what matters to them and then twist, you know, the outcomes to to be motivating for that person. So I think, yeah, I don't think we should underestimate the power of of that, of what EPS can do in that way too.

SPEAKER_01 18:38

Absolutely. So it sounds like it was a bit of a serendipitous moment to um go into the exercise on oncology. What um what motivated you to stay there long long term? What was your um yeah, sort of reason why you uh decided to commit to that? Is that just in your nature? Is that something that you know you saw more problems and want to solve them?

SPEAKER_03 18:58

Always since I started working with cancer, I just have loved being in that field. It just, it just, there's something in my brain that just loves working with it. I think, I think also maybe my ADHD brain, we tend to excel in areas that might be scary for others, like really in that sort of I don't want to say crisis point, but we're we're good in an emergency. We're good in those sort of high intensity moments. And I think that's what cancer is. Uh you know, it's this very special moment in a person's whole life. And it's not for everyone, you know. But I some days I find it heavy. I mean, I feel the full weight of the privilege of having that person's time, but mostly I just see it as a joy that I get to help this person help themselves. And I think that's why I've always loved it. And, you know, if you think you can see the differences in older adults who are otherwise healthy, the differences you can see in someone who has had treatment or is about to have treatment or is experiencing other problems, frailty at the same time during cancer, um, and and helping them get back to moving or find movement. I mean, it's truly spectacular. So I think that has that has helped me. And I we've had a lot of people in my family die of cancer. And so it's sort of personal, and that has given me insight that I think I've sort of got on this mission. And then I think I've just something in my head, I've got this mission now that I want everyone in Australia and Sweden who would like exercise to be offered exercise as part of their cancer treatment, no matter who they are, no matter where they live. That's my goal. And it's just it's in my brain now.

SPEAKER_01 20:58

So, oh, that's awesome. Um, so I guess on on the note of that, that mission, um, I've got a couple of follow-up questions. And I think the first one is going to be a pretty, pretty obvious one. Do you think exercise should be an essential part of treatment?

SPEAKER_03 21:12

Yes. I think, I think now this is where I believe in a lot of nuance. I think that everyone should be offered the opportunity to discuss exercise and have a referral to an exercise professional. I don't think that we should say to everyone, you must exercise. Everyone chooses the sort of life that they want to live. Everyone, and particularly in the field time of cancer, you know, there's quite a strong feeling from people, you know, the patients that I've heard that someone's saying to do this, you're you're having to do this treatment, and people lose a lot of autonomy. And so this is something that exercise, you can give autonomy back to people, empower them to make their own decisions. It's their life, they can choose what is important. To them, sometimes people have another 10, 20 years to live. Some people only have months or a year. And then they should be able to choose what they do with that time. So people should be made aware of the benefits so they can have like an informed consent to being involved. They should be given the support, all the support that they need to exercise. So there's my there's my nuanced approach to that. Yes. Yes is the short answer, and that that was otherwise my long answer before that.

SPEAKER_01 22:30

No, uh definitely, I definitely agree. Yeah, I think it is really important, like you said, Kate, for people to see specifically an EP. I think um if they were to see their GP or doctor in the hospital and then they said, Oh, would you like to exercise with your treatment? It's like, well, is that a GP the best person to provide education around exercise? Probably not. You would you would assume an EP would be, just like uh a dietitian would be the best person to provide exercise on advice on diet. So I yeah, I I definitely uh agree, Kate, there should be a hundred percent at least one referral off to an EP as part of the essential healthcare there, and then leave it with them to decide after that. In saying that though, we obviously know that behavior change doesn't take place in one session. And so that does make it tricky. But uh what would you foresee being a reasonable amount of referrals to an EP to and this is obviously gonna be person dependent, but if you had to standardize how many referrals to an EP as part of exercise on college treatment, how many would you say?

SPEAKER_03 23:40

How many sessions? Yeah. They should get, as many as we can push for. As many as we can push for. I'm not gonna limit it. I mean, is five enough? Probably not.

SPEAKER_02 23:50

Yeah.

SPEAKER_03 23:50

I I mean, as many as that person can can get, that's what I'll say.

SPEAKER_02 23:54

Yeah.

SPEAKER_03 23:55

As many as I can get. And I mean, this is the balance the whole time, and this is what we're working with in Sweden too. When you have this sort of an equity lens and that everyone should, we need to create systems where everyone should be offered the same no matter where they live. So that's sort of the tricky part all the time that a person who's living out in Alice Springs, where we've got our excellent EP of the year comes from, you know, she's really trying to get EPs out there. Um, so they don't, you know, maybe they don't have capacity to send absolutely everyone who's got cancer to to an EP there, even though we'd love that. So I think there's about, you know, the way we're working in Sweden is having, you know, different levels of intervention. So we're saying everyone should at least get information about the benefits of exercise, written, verbal. Everyone gets that. And then those who need it or want it should get a referral to an exercise professional. And I keep saying exercise professional because it could be a physiotherapist, it could be an exercise physiologist. And in Sweden, we don't have exercise physiologists, so it is a physiotherapist. We're also training up personal trainers in Sweden to be experts in cancer and exercise. So I'll just keep pushing until everyone can get it who wants it. That's my goal, really. But we have to work within the constraints of the Australian health system.

SPEAKER_01 25:20

Yes, yes, we do. Okay. On on the sort of uh the topic of of Sweden, so what's the what's sorry, what's the current research or sorry project that you're focusing on at the moment? Is it that tiered tiered level of um health regarding exercise?

SPEAKER_03 25:37

So Sweden has just had an absolute rapid increase in engagement with exercise oncology in the last five, ten years. You know, there's been trials in our group when I was in Sweden, you know, 10, 11, 12 years ago, they have have existed. But it's really starting to catch the, you know, the doctors and the nurses now and the policy makers. So there is a network. We work really nicely together in Sweden. There's everyone works together. Um, and we come together and we share ideas and we are moving forward in the same way. And I think that is the power of that cannot be underestimated. So it's a very inclusive environment, and we have come together and have tried to brainstorm ways to implement exercise into cancer care. So there's nurses, doctors, patients, exercise professionals. And so they've come together and it it was decided that, okay, you know, that the evidence is there now. So how are we going to implement it? And it was identified that, so in Australia, we have optimal care pathways. And that is our, you know, if you have cancer, press breast cancer, prostate cancer, that's how you should that's best best practice. They exist out there so everyone sees them. So the equivalent of that in Sweden is called the NVPs, Nachuna Lavoe programme. They don't have exercise within them. So there are 53 of these for all the different types of cancers, and that there is no section in there that has exercise. No one's being held to account and exercise. So it was established that that's a great step forward. So that's what we're doing. We are inserting exercise and how exercise should be discussed, engaged with, referred the evidence for each of the cancer types, how that will work within the cancer care system. For we're starting off with four cancer types and seeing how that goes. And so that's the project we're working on now. We have, I think, 25 states in Sweden. So we need to engage with all of those different stakeholders, the 25 different like healthcare systems. Okay. Um, and then yeah, it's quite tricky. So we have quite a bit of disjoint, disjoint sort of um delivery of care. So that is a bit of a challenge. But that's what we're working on now. So we're going to create that small little portion there that says, you know, yep, you've got prostate cancer. Here's the type of exercise, um, the evidence and how a person should receive information about exercise and the referral pathway, who should be referred, potentially making a new form to bridge the gap between hospital care and community care, which is a bit of a problem in everywhere in the world. And then probably we're also creating like a support document, which is sort of similar to our really great booklet that we have in Australia that the Cancer Council made with the researchers here. So there's people get them with more in-depth information about exercise and cancer and how they can practically do it. So that's what we're working on.

SPEAKER_01 28:49

There's a few questions I have from that, and just making sure I that I write them down so I can remember to ask them. The first one is back to what you were saying around the states and them being perhaps not as organized as what we have here in Australia. For example, we have the Medicare system, which is nationwide, but then the example is work cover, I don't think is as applicable across all states the same. Would it be a little bit like work cover here in Australia in terms of that it has a little bit of uh not the same standard or same equal level of care across states?

SPEAKER_03 29:22

Yeah, I think the the big issue is that sometimes they, you know, this is sort of a new area. So any new programs or models of care or models of service delivery um or standards that are rolled out are often different in those 25. So some people will have access to this online patient portal, which also has information about exercise, but the county over doesn't. So, you know, it's even you know, sometimes even the screening rules are different.

SPEAKER_00 30:01

Interesting.

SPEAKER_03 30:02

Yeah, it's a challenge.

SPEAKER_00 30:04

You got your hands. It's a challenge. Okay.

SPEAKER_03 30:07

And I think that's why I mean I again, I think the ADHD brain loves strategy. And so I think that's why we've gone for the national level with the optimal care pathways equivalent in Sweden, because you know, when it comes from a national level down, then everyone gets the same. And that is, you know, you know one of my other core beliefs that everyone should be have the same access.

SPEAKER_01 30:32

Yeah, absolutely. Absolutely. So it's really interesting to hear like the how different ecosystems interact with each other and how you you have to sort of fit in with the ecosystem. Obviously, there's sounds like there's things like uh politics, obviously, geopolitics, there's economy, there's the financial side of things that all play a role in how healthcare and of course here in Australia, I think generally speaking, Australians are sort of renowned for having relatively okay healthcare, at least that's what I assume. But then you look at places like the US and and maybe your healthcare system isn't as privileged as us here in Australia. So um, yeah, there's always someone doing a little bit better and someone doing a little bit worse in certain scenarios.

SPEAKER_03 31:13

And I think you just have to be pragmatic. You know, sometimes I'm very opportunistic and optimistic and, you know, live in a fairy world. But often I'm very pragmatic because it is the only way forward. And, you know, I I yeah, I've got friends in America who are trying to implement exercise into cancer care, and they would not dream of doing it in the public sector like I'm trying to push it through in the public sector because it just it's just not how America works. Whereas in Sweden, it must be the public sector also. So I think it and this is why I think we really need more, you know, EPs, clinical EPs working in the real world. There was a great talk at ESA on the public sector. And the knowledge that these EPs had must come into the research world because I think it's the missing link really to developing, like getting things in. Like we can do implementation science and it's really important until we're blue in the face. But if there's a like a pragmatic location-based situation, you know, we we just need that pragmatic approach to get it through.

SPEAKER_01 32:21

Yeah. Yeah, no, I understand where you're coming from. And my the other question I had was just around the book that you mentioned by I think the Cancer Council. What was that book called?

SPEAKER_03 32:30

Yes, what is it called? Cancer and Exercise? The I think it could have been even Western Australia Cancer Council started it. But if it it's the it's the main cancer and exercise booklet, it should be on the Cancer Council website. You can also order hard copies. It's very often the booklet that is in all the cancer clinics. It's an excellent book. It's quite thick. It's like 62 pages. And I think it's a really nice read for people to take home. Again, some people like to digest their information slowly. Often it's very overwhelming. So I think it's nice to have that that option. It's a good, it's a very good book.

SPEAKER_01 33:11

And that's for patients, not for EPs?

SPEAKER_03 33:13

It is for patients.

SPEAKER_01 33:14

Yeah, cool. And was it more of a informative so uh and I know I could just look this up, but um was it more informative or is it more Yeah, so it's got it's got the benefits of exercise, which I think is really important.

SPEAKER_03 33:27

So it's got it got that in there, but it also has examples of exercises that they could do. Because I think we keep saying to people, you know, here's the guidelines, and then but how do we get those guidelines into a doable exercise program for people who have just started or have never exercised before? So that I think it really bridges that nice gap. Yeah. But it's got like resources of who to contact and yeah, it's it's really nice.

SPEAKER_01 33:53

Yeah, fantastic. Yeah, well it's it's really interesting to hear about the differences between um Australia and, you know, say places like Sweden. From what I was aware prior to this conversation, Kate, I thought Sweden, you know, Norway, Switzerland, all those places had it sort of figured out when it came to the healthcare system. At least that was for my knowledge. But I think uh I think they do.

SPEAKER_03 34:13

They do generally, but um and I'd say Norway is certainly ahead of Sweden in terms of exercise physiologists and they have they have the the premier, I would say, exercise oncology center, scientific center now. It just got just got opened. So they're certainly doing excellent things there, but we just don't have exercise physiologists in Sweden.

SPEAKER_00 34:36

Gotcha.

SPEAKER_03 34:38

Yeah, we just we just don't have them. So we just have to work with that. But otherwise the health system's very good.

SPEAKER_01 34:44

You mentioned before about being pragmatic and sort of, you know, we can do implementation science and I think until we turn blue. Obviously, the work that you're doing at the moment is improving the actual cancer care systems and how that fits into an ecosystem at a state and national level. How do you foresee the translation of that into Australia, not just around oncology, but I guess in a broader sense, improving the policies that we have in place to get recognition for EPs? Because that's a big thing that E I think have a problem with is um how we're communicated in the broader profession. And I think it's definitely gotten better, and I'm sure you can speak to this in 2001.

SPEAKER_03 35:26

Yeah. I think it's I think it's fascinating. And I wonder if we need to be better at teaching this into our courses. Again, that I I go back to that session that was on Sunday at Essa, and Luke was there, and Grant, I think, was another one of the great researchers. I mean, presenters there, and Katie and Anita, and people should really listen to it if they can get their hands on that audio. But what they did say is again, it's a lot of pragmatism. You know, we do have, I mean, we're we're on the eve of budget night now, and we do have limited budget. That's just the reality of it. But what I think we need to do a better job of is communicating what we're good at in a language that is attractive to those who make the decisions. So, for an example for me would be that, you know, I think, you know, we measure muscle strength. But what that actually means is that we're preventing frailty. And when we prevent frailty, we're preventing falls. And when preventing falls and frailty, what we're also preventing is hospital readmissions. We're reducing length of stay. We're reducing people from having fractures and being in the hospital longer than they need to be, getting this, you know, hospital-acquired frailty, and then maybe then needing to go into residential aged care facility or being stuck in hospital, which in the other end increases ramping at the beginning. So these are all the things that we can really do. And I think Luke did a great job of, you know, he's in his work in Nambo. I think he, by thinking like a hospital director and doing a really good job of advocating for the things that we're good at in the language of Queensland Health. I think he's increased the FTE for the team there from six FTE to 55 FTE. I mean, it's actually just incredible. So I think we just need to um start speaking that language. And I know that there's some courses now, but when models of care and models of service delivery get written in hospitals, we must be the ones to be involved or to write them. We're not in those rooms, we're not in those discussions. We are sometimes, but I think we can absolutely do a better job of being in those discussions. You know, if you've got a multidisciplinary team meeting for cancer for the cancer clinic, yeah, exercise physiologists should be in those rooms. So we just need to be in the rooms where the decisions are getting made a bit more.

SPEAKER_01 37:59

Yeah, I I guess on that topic. That's a that's a really great point, Kate. Um, and I'm I'm really glad you said that because um I was just thinking back to one of my own clinical scenarios that happened most recently. One of my clients has just been told that his uh PSA levels have scarbured after being cleared after chemotherapy, and he's had to essentially they've told him he needs to get back on treatment. And he was weighing up his possible scenarios regarding what treatment to adhere to, and there's apparently a new one, some sort of radiation therapy. It's not one of the newest ones. That's quite expensive, but it does have sorry, it's one of the newer ones that has less research behind it, so it's a little bit less expensive. Regardless, um he was uh unsure as to whether the treatment was effective, what the what the research was around it, and also wanted to know what he can do before treatment, during treatment, and after treatment. And his oncologist uh referred him off to someone else that was the CEO of the company that designed this treatment and also referred him off to the Doctor in Studies Insurance Company to have a conversation. And I I guess would it be even more beneficial for the EP to be potentially become more of a concierge when it comes to this sort of things? Because we have the most patient interaction out of all of those doctors. If we have the best understanding of the patient, that can really inform outcomes when it comes to treatment and what they can do via performance. So, how do how would we go about getting in those spaces? Do you think it's just a matter of reaching out to these doctors or other providers via email? Do you think it's something else?

SPEAKER_03 39:42

I think you could absolutely contact by the email. I think PrueCorm is doing great work in this area in terms of overcoming the challenges with doctors and nurses feeling like they can, you know, engage on exercise in this. So there's lots of different things that could be done. And I think there's lots of things you could do at a, you know, individual level. I think you could absolutely contact the nurse or the doctors in your local area and say, like, here's my skills. Because you could imagine that as a doctor or nurse, trust is a big thing, you know, and this is what doctors and nurses have said too. We don't know who to refer to. So I think the message is getting out now, now for the most part, that exercise is good, exercise is safe. But I think that they're also, they really care about their patients and they want them to be well looked after. So I think one option could be, if just at a, you know, individual level is is going in and saying, like, here's here's what I can do, here's the referral pathway, you can refer to me. At a national level, I think, you know, and this is what Pru's work really is doing, is trying to understand where we're not meeting the needs of the doctors and the nurses. And we're doing that in Sweden now too, trying to understand what is missing in those discussions. And very often we have found, and this is also what the research has shown, you know, that the doctors are very busy. And so exercise sometimes really doesn't come up. That's just a bit how it is, even though there's a lot of power in doctors saying the benefits of exercise. But the people who spend a lot of time with these people are the nurses. Really, you know, they're contact nurses in Sweden. And here we have cancer nurses and we have coordinators and they're the people who spend a lot of time with patients. And some of the feedback that we've been getting back is that some of them are not, because it's not standardized, like this is not a standard component. So it's, you know, when you get the choice to bring it up or not, you can make that choice. It's not on a checklist. And some people are not bringing it up because they don't feel confident to speak about exercise, which you could imagine, like if you sort of if you say exercise is good for you, and then the patient says, okay, what should I do? And if you don't feel confident to say that, an optional discussion then becomes you're not going to do it. So that's what we're also trying to work on now. There's another project that's an upcoming where there are quite a few people who are trying to work on this now. And Rosa Spence is also working on a new project that is going to create, you know, free-to-access resources for the MDT, nurses, doctors, anyone who would like to learn more about exercise, and then also for the exercise professionals who would like to learn more about working with people for cancer. So I think there are quite a few people who are now doing good work in this area, upskilling. So I think that that will help. It'll just open the door.

SPEAKER_00 42:32

Interesting.

SPEAKER_01 42:33

Yeah. I think that's a really interesting point around, yeah, if you don't feel confident in the room of talking about a particular topic, then yeah, chances are you're not going to raise it up. Just trying to relate it back to an EP scenario for the EP listeners, it may be something like, for example, diet. And for a lot of EPs, that we could speak a little bit about um the diet having done the very small amount of curriculum inside university. But I think if we perhaps hadn't have hadn't had done that curriculum or you didn't have a prior knowledge of diet, then maybe opening the conversation around that to a client to then refer off to a dietitian would be less likely to happen.

SPEAKER_03 43:11

Yeah. And like everything, I mean, people want people want to help these people. So no one's being vindictive, no one's doing that. It's just people who not have the capacity. So I think our job, particularly, I think my job as a exercise in cancer research is to help people have the capacity to do these things. Help the patients have capacity, help the nurses and the doctors and the physiotherapists and everyone have the capacity to deliver the services that we know are best practice.

SPEAKER_02 43:41

Absolutely.

SPEAKER_03 43:42

Support. That's the key. Support, not shame.

SPEAKER_01 43:46

No, absolutely. And so are you are you sort of in charge at the moment of the this sort of larger scale cancer survivorship and an exercise implementation in Sweden as as well as something in Australia?

SPEAKER_03 43:58

Yeah. So at the moment that's one of my jobs is to lead that project. With there's a group of us who are who are working with it on colleges and so do everyone, but but uh my job is to lead that. Yes.

SPEAKER_01 44:09

Yes sorry, you go.

SPEAKER_03 44:11

No, that's it.

SPEAKER_01 44:12

I was saying my follow-up question to that was uh how do you go t uh go go, sorry, how do you go uh managing that team and and delegating the relevant tasks underneath us? And I know this is getting into a slightly different topic, but for some EPs on here as well, actually there's a statistic that came out that said a lot of EPs are business owners and they have a team of people underneath them as well that may benefit from hearing a slightly different perspective when it comes to managing and delegating tasks.

SPEAKER_03 44:40

Well and I'm gonna tell you it from an ADHD brain type of way because I have to say project management, many people with ADHD are very good at project management. Just like we're very good at putting lots of reminders, we often become, you know, hypervigilant or very good at the thing that is really tough for our brain. But you know, for a person with ADHD, asking us to put timeframes on things and project managing for me it's very tricky. It's super tricky. So I have like all the strategies, all the reminders and and often I will work with someone who is much better at that. So I feel like I'm not going to give too much advice just to say that if you're listening and you do have ADHD and I know that a good portion of exercise that have ADHD like I see you that it's hard and you know I suppose you just got to lean into other strengths. So but what do I do practically now? Because I do have you know these 25 different states and we've got this you know the deadline this needs to be done by October. So I just I suppose I have a lot of visual reminders and yeah I just have a lot of reminders in my phone and I try and be just really really really clear with expectations at the beginning so that everyone feels really comfortable at the beginning. Make sure everything is like there's no assumed roles or everyone just feels really comfortable at the beginning and then just quite good check-ins. But yeah, there's certainly not my strong point. Sorry everyone who's worked with me I think honesty is a really good uh characteristic in in leadership as well yeah I think so I think so and you know we're all good at different things.

SPEAKER_01 46:26

Exactly um yeah no I I definitely think though those two points that you did drive home are are probably the most important ones the initial initial expectations and checking in absolutely yeah with with I guess the setting the expect the the initial expectations now some people may have different viewpoints on what that is in terms of does that look like an entire just checklist of yep yep yep tick tick tick or is it more about um installing certain values and behaviors? What does that look like?

SPEAKER_03 46:56

Most of my experience has been with has come with projects like working on big projects you know we worked on big EU projects you know across cultures. So I think it is about having really long discussions and in my field it looks like how much time do you have to work on this? Like what is what is your capacity to work on this? What do you want out of it? Like what is important to you out of this? And I think that's a really good question because sometimes it's really easy stuff that I can achieve for that person that I would never have thought of. But like it's actually an easy win you know they want to learn about this. Oh yeah I can teach you that that's no problem. But you know so yeah and then also understanding capacity of that person like, you know, I'd like to be involved but I can only give you an hour a week and then I make that decision whether that's enough. So I think it is having very honest and there used to be really awkward conversations for me, but I was in too many situations where you'd get to the end of the project and then yeah there's just conflict that could have been avoided at the beginning. So I think that that's you know it looks like who's going to be on the papers for us, you know, where do you where would you see yourself being on the author list you know silly academic things that actually matter because it's what gets people career progressions, you know. So all those sort of things but I really I love a good long discussion at the very beginning until everyone feels feels comfortable and feels understood.

SPEAKER_01 48:30

It's a little bit like um almost as if you're on onboarding a a new a new patient or a new client. You spend that extra little bit of time and service delivery at the start to ensure that they have a smooth onboarding process so that later down the track, you know, the expectations are already set they stick with you longer longer.

SPEAKER_03 48:47

Yeah. And I think everyone feels um heard and can relax when they know what's going on. And it's the same with co-design, like when we're co-designing projects and being very clear with people with you know maybe someone who's got a lived experience of cancer or being a carer you're very clear about, you know, here's here's what we're about to do, here's what we want your input on. And when you're very clear about that, you know, you could obviously the other way you could be like we just really care what you think in general. But actually what we really care about is this part because we we can't our project isn't about that part. So but if you don't have that discussion at the beginning then they'd be like why didn't you listen about you know how much nausea I have well we can only act on on this part here.

SPEAKER_00 49:35

So that's an interesting point.

SPEAKER_03 49:37

It just helps people to feel more heard.

SPEAKER_02 49:40

Interesting.

SPEAKER_03 49:40

Yeah. Yeah and it I'm still working on that a lot. It's really tricky. But uh I think if you come at it from just respecting everyone's time and capacity, everyone's busy, everyone's overloaded I think it's a good way forward.

SPEAKER_01 49:54

Absolutely going on to a little bit more of a practical sense for EPs listening in terms of exercise oncology and the sustainability of that. Do you believe that there are going to be more exercise oncology specific practices that may open up in the future in Australia?

SPEAKER_03 50:08

We're only going to increase like the capacity and the you know capacity for exercise physiologists to work in cancer is only going to increase. I like to think in the future with the healthcare system is how I like to think. And if you think now that our hospitals are overloaded that's just everyone knows that there's ramping you know we have a big problem. So we will get to the point and we're certainly in the point now in Sweden and probably in Australia where only the people who must be in the hospital will be in the hospital. If your care can be given outside of the hospital then that's where it must be in the community. And so that's where I think we are moving to and there are forward thinking HHS think to people the listeners will know like a you know Metro South health hospital and health service. So you know you've got Metro North you've got Metro South all the little the hospital and health services within you know Queensland Health and all the different ones. So I think the more progressive ones are seeing the benefits of exercise for the people with chronic disease in terms of helping that flow through to the hospital and you know helping them stay out of hospital. And so I think this is the role of the EP also community health I I think we have to really push and the benefit of the community health for cancer, for diabetes for anyone, I think that's where we need to be sort of working in terms of, you know, we used to have a model and this model is still appropriate for some where we would have a physiotherapist drive to one patient's house, come back to the hospital, drive to another patient's house, come back to the hospital. Whereas the more progressive, I would say HHS are seeing now that if we can have group or virtual training in the community, we can see a lot more people. So instead of five people having optimal care, we can have 500 people having optimal care. So I think exercise physiologists who can get involved and lead those models of community care, I think that is also the the face of cancer care. No, that there'll still be a place for exercise within hospitals, yes. But I think if we're looking to where the puck is going, as that saying says, I think it it will be also outside of the hospitals.

SPEAKER_01 52:30

I I 100% uh agree on on on that and I love the forward thinking Kate. Yes yeah I think that's a really good point coming from the point of hospitals are overflowing. We need to be able to help as many people as we can and help more people we can't do that um if the you know um if the hospitals are already at their limit. And on top of that like you said reserving the hospitals for only the most critical care patients rather than um anyone and everyone being in there. Because I think imagine I imagine there's I'm not sure if there's any research and you've whether you've looked into any research around this around what's the quality of life of people inside the hospital versus those that go to a community orientated clinic.

SPEAKER_03 53:13

I don't know. I mean I I think it depends very much on what your community you know situation is at a residential aged care facility are you getting back to your home those sort of things but I think we know now that people who stay in hospitals for a long period of time and less intervened on by exercise professionals, which I think is another huge role for us, you know, there's people who are these long stay patients within hospitals and we know that they that stay, the long hospital stay increases their chances of hospital acquired frailty. I mean that I mean tell me that's not a place for an exercise physiologist to go in there like the good stuff we could do in helping that person to do you know targeted like great exercise not under prescribed exercise in those moments I mean we could just there's so much power in there and I know that people have done trials you know a little bit in that area my friends mentioned one but I think there's there's such potential for us to go in there to prevent that that frailty it's causing huge problems.

SPEAKER_01 54:21

Absolutely sort of um to sort of wrap up a little bit in terms of the exercise oncology side of things and to look further forward as I love the the projected further forward thinking what core competencies do you think EPs need to work on more confidently? Like what are the key core competencies EPs need to work on more work on to work more confidently in the exercise oncology space?

SPEAKER_03 54:45

I think the key things is to understand the treatments and under the side effects attached to those treatments. You know there is no one exercise program that I would prescribe for someone with prostate cancer. It's about meeting the person where they're at which EPs are great at doing anyway. So I think you just have to understand the treatments and then the side effects of those treatments and understand you know there's ebbs and flows of the treatments. So that's that's number one. I think number two is behavior change because these people are having a tough time. Also that's what exercise physiologists are amazing at. And I think you know in in public health in general like if we we're trying to convince hospital directors policy about getting people independently well, that is what exercise physiologists are amazing at. And then I think number three, which is a bit of a strange one, but I think it's really important right now we are not doing a good job of reaching everyone. We're not doing a good job of reaching people who are living in regional rural remote areas. We're not doing a good job of reaching Aboriginal and Torres Strait Islander people with care that is culturally appropriate, culturally safe, people from different cultures so I would encourage people to sort of think about who's being left out of the care that we're providing at the moment and that certainly is those people. So educating ourselves on how different cultures needs are different when they receive healthcare we just need more Aboriginal Toshade Islander um diverse exercise physiologists we we just need so many more. So they're my top three skills I think.

SPEAKER_01 56:25

Yeah no I I I love it all. There was Robert DiCasso, also known as Deke that I'm not sure he was uh at the Essa Activate conference the other week and um it was the first time I've heard of him and he I think he won like the world marathon back X number of years. And from winning that he's now ended up using a lot of that that fame and recognition that he established or or acquired to now start a program called the Indig Indigenous Marathon Foundation. Yeah. Rob D Costella Yeah Robert D Costella sorry I got the name wrong. Yeah yeah yeah yeah I think the work that he's done in the face uh in the space is fantastic.

SPEAKER_03 57:06

Yeah we so one of our programs that the other sort of thought that I have all the time is who are we leaving out? Who's being left out who who are we missing here? And when you ask that in every scenario I I ask it when I wrote my exercise trials who's being left out when I write it like this because you're always leaving someone out. So then how do we how do we provide care for those people that we currently are not and so that's also what sort of led me to work a lot with Indigenous health and we started up with you know after chatting and chatting and chatting to different people and chatting to Ray Kelly and all sorts of people I now work with a brilliant Aboriginal controlled organization in Port Macquarie, Strong Spirit and that is run by Jess Morris. And so I worked with them and it's been a different way of working but it's a beautiful way of working the way that Aboriginal health delivers itself. If everyone worked the way that Aboriginal health we'd all be better off. And so we had the discussion do we just adapt the current cancer survivorship model or do we just burn it down and build a new one? And that's we've done a bit of both, I think. So Jess leads that project, which is the important thing because she's the indigenous woman. So she's she's the leader of that with the self-determination approach. And I just sort of support from the back trying to I just let her know, you know, what is the evidence for exercise and and we've got diet in there and cultural mindfulness and so we built this new cancer survivorship program, the very first one that's ever been designed by Aboriginal people and community through yarning for Aboriginal community led by Aboriginal community. And so we're just piloting that now but I mean if you think Aboriginal Torres Strait Islander people are like a prior they are a priority group. We've got these priority groups in Cancer Australian plan. And you know we've got so much evidence now on exercise within cancer survivorship and survivorship is all the part of cancer that is not the treatment. And yet we have no exercise trials no evidence on the role of for Aboriginal Torres Sharina people. They're just completely left out of our trials completely, you know, left out of designing new survivorship plans. So anyway we've had enough of that and so it's just I have to say it is the joy of a lifetime to work in Aboriginal health. I'm learning a lot I'm not indigenous myself so it's been a very big learning curve but I think anyone if you are indigenous and you're listening and you're an exercise physiologist please feel free to get in contact with us or anyone who's thinking who wants to become an EP, please do. Like we need you. Yeah and I think that's a huge space you know this is a tiny pilot that we've just started. There's so much space for more more work in Indigenous health and cancer and exercise survivorship and also cultural and linguistically diverse populations. There's very little on that too so if anyone's interested in that they can contact me too.

SPEAKER_01 1:00:12

What's one topic or issue you think EPs should be talking about more openly with each other?

SPEAKER_03 1:00:18

Who are we leaving out? That one I think so I think I think it should be asked when designing anything new you know people with a disability you know by design so many things we leave people out. And sometimes it's better for them to be left out because actually we should be creating a whole new program or service for that person. But I think we we often EPs you know we're often quite a privileged bunch. Um and I think you know even even just from the perspective of most people like exercise as exercise physiologists. I don't really I I've never really been that I used to call the hippie of HM back then. So you know who are we leaving out in in so many different ways in terms of you know people who might not like exercise or people who might not put their hand up for exercise or people with a disability, First Nations people, you know, people who live in the country people who don't have access and I think there is so much space for for research in this. And I actually think EPs working in the real world are Chef's Kiff's perfect to work in this field in research because it usually takes a very high level of thinking and experience and expertise that comes with practicing in the real world and seeing how things work in the real world. So I think any EPs who want to get into research in any of that space in terms of equitable care to exercise should now is the time to do it. Yeah.

SPEAKER_01 1:01:50

Love it Kate if people want to get in contact with you or um look at any of the research that you've done where's the best place they can get all that I can put I've got about four email addresses and I will give you one.

SPEAKER_03 1:02:04

Will you attach it to the notes? Yes shall we do that? Yeah so we'll do my email is there people can do that. You can find me on LinkedIn and I think it's my full name there Kate Bolum Ianason you'll see that my Swedish name is in there too. I think LinkedIn is a good a good place to catch me. I mean my publications are on PubMed but I'm happy to share with any of them if any of those are blocked or not open access I'll just email them to you. You can just let me know.

SPEAKER_01 1:02:29

Thank you Kate really appreciate having you on this has been a this has been a fantastic chat.

SPEAKER_03 1:02:32

Thanks very much for having me. I appreciate it.