Hello everyone and thank you for joining. My name is Brigette Cole. I’m the programs manager at Nevada Cancer Coalition. I want to thank everyone for joining our first webinar clinic and our Cancer Survivorship Project ECHO series. So, today’s webinar is on fitness. A brief overview of positive impacts of fitness before, during and after treatment. The Coalition in collaboration with Project ECHO is providing this series to primary care providers as an introduction to issues in cancer survivorship. Today, more than two-thirds of those diagnosed with cancer are told that they can expect to live at least five years after diagnosis. According to the American Cancer Society in Nevada.There are currently an estimated 120,200 cancer survivors. In 2019, 14,810 people will be diagnosed with cancer in Nevada. So, this series hopes to address survivors ongoing needs with improved outcomes and quality of life for cancer survivors. Nevada Cancer Coalition is Nevada’s statewide nonprofit. We bring together organizations and individuals across the state to collaborate on all things cancer. We provide information and education to both the community and healthcare providers. Including housing the state’s most comprehensive resource directory. We develop and implement cancer prevention, early detection, and survivorship initiatives and programs. We work on policies surrounding cancer and improvement of our healthcare system. So, please take a look at our website. We have a lot of really great tools and resources for providers. We have infographics for early detection, screening, key messages, social media toolkits, recall reminder postcards, decision information guides and much more. If you have any questions in regards to any of that information that is on our website you can always reach out to me. Once again. My name is Brigette Cole and my email address is [email protected] but you can find that on our website. Did we want to do introductions? Yeah, sure. Let’s go around the group here and see who we have joining us this morning. We will start off with Sue. Sue, can you hear us? Could you introduce yourself? Okay, maybe Sue doesn’t have a microphone. So, we will go to Shauna Pascal. Could you introduce yourself? Hello, my name is Shauna Pascal and I’m with the Women’s Health Connection with the state of Nevada. Great, good to have you this morning. And then is it Illian? Hi, my name is Irene. I’m a nurse navigator at Sunrise Hospital, Las Vegas. Great. Good morning and thank you. And then June do you want to introduce yourself? Hi, Sure. Good morning. Hi, my name is June Hunter and I’m senior manager for the American Cancer Society. And also a five year breast cancer survivor. I’m super happy to be here and help launch the ECHO Project. Thank you. Great. Good morning, June. C. Ponce? Just a second here. could you unmute yourself with the icon in the lower left corner here? Yeah, go ahead we should be able to hear you. Yeah, we can hear you. Hello? Yeah, go ahead. This is Carmen Ponce a biostatistician with the Cancer Registry. Great, good morning. Dr. Lavi? Hi, I’m Mordechai Lavi a UNR geriatrician and also a medical director here at Project ECHO. Thanks. Then someone LRH, but it doesn’t look like they’ve joined the audio yet. So, we’ll go to Mala? Hi, this is Mala. I am the Cancer Registry Manager from California Fountain Valley Regional Hospital. Alright, thank you just a little trouble hearing you there. No problem. Inaudible Robin Palmer? Robin are you there? Do we have a microphone for you? Okay, maybe no microphone for Robin. So, we have somebody that is calling in 775 area code 2308252 could you introduce yourself? Okay, well that’s alright. Thanks everyone for joining us again. Let’s start it off and see if anyone has any questions that they want to bring up before we get going. Anything that you’d like to ask? Feel free to take yourself off mute or write in using the chat function. We just had a group D Garcia, could you all introduce yourselves? Good morning, I’m Dora with Access To Health Care. I’m the Medical Discount Program Manager. Good morning, I’m Karina and I’m a Cancer Care Coordinator. Hi everyone, I’m Denice and I’m also a cancer care coordinator. Excellent, it is great to have you all here this morning. Thank you. Okay, so we will get going here then. I would like to introduce you to today’s presenter Christina Gardner. Christina is a Cancer Exercise Specialist for Saint Mary’s Fitness Center Cancer Rehabilitation Program. She’s been in the fitness industry for 18 years and is a certified trainer in group fitness, pilates and cancer exercise. Christina has a passion for teaching and helping others find confidence in moving their bodies no matter what is going on with their health. As Christina puts it, Fitness is never a destination. It is a journey through the mind and body. Her goal is always to find a way to make fitness fun for all to enjoy. And I just have to say she absolutely does that. She’s quite amazing. So without further ado I would like to introduce you to Christina Gardner. Hi Good morning, everyone. Like Brigette said I’m Christina Gardner. I am one of the Cancer Exercise Specialists at Saint Mary’s. For today’s presentation I’m just going to go over pretty much the basics. Then introduce the actual program that we do at Saint Mary’s and how it’s open to all cancer related patient survivors. You’ll see that throughout the presentation today. The main focus is just kind of what exercise does for cancer and for the patient’s mental health and etcetera. So we’ll go ahead and get started. Our objectives today, I’m just going to briefly talk about general benefits of exercise and the benefits of cancer survivor’s. The recommendations that we have not only us but also one of our organizations that we work with. Then special considerations that we look at as a cancer exercise specialist when we go through the orientation process with our clients. We call them clients not patients. Then also kind of what the role holds for the Rehabilitation Program and how we work with other doctors and physical therapists in the industry. Some general exercise benefits we all know it does control weight and reduce obesity. It lowers hormone levels, reduces fatigue and anxiety and pain. Also reducing the risk of inflammation, cardiovascular disease, type 2 diabetes or metabolic syndrome and some cancers. Through exercise improve bone, muscle, balance and flexibility. I turned gestational function, immune system function and ability to perform activities daily. Increase your chances of living longer. So as we know exercise is great for our body regardless of where we are with our health. Some of the benefits to cancer. We’ve seen a link to breast cancer in particular with thirteen different cancer. Exercise has been shown to reduce the risk of developing breast cancer in women by 12%. The body fat and weight gain before and around the time of diagnosis can’t increase the risk of recurrence and death and in prostate cancer. Exercise has been shown to reduce the risk of developing colon cancer up to 40%. Recent evidence has shown the obesity that linked to the risk of cancer progression. We’re also finding that cancer thrives off the sugar and fat and so the higher the obesity rate with the patient at the time of diagnosis the higher the risk. Studies have shown that exercise can reduce the risk of cancer recurrence up to 60% which is pretty high. Considering that just a daily movement of 30 minutes a day can make an improvement our clients and our patients. The recommendation with American College of Sports Medicine recommends the following for all of the adults 150 minutes of moderate intensity exercise Per week. That’s 30 minutes five days a week or every other day. We look at cardiovascular strength flexibility and then just activities going on hikes and what that can do for the body. And then how can this be broken up? A lot of people that may have never exercised or have been exercising and recently been diagnosed. This seems like a lot for them. As a cancer exercise specialist, we really try to break this up for them. In the sense of giving them ten minutes of cardio, ten minutes of strength if they’re up to it. I’ll talk a little bit more about fatigue and all of that as we move further. If they can’t meet these recommendations, we really try to start very slow. Like go for a brisk walk two minutes get up from the couch walk around the couch come back and sit back down. We really try to work with the clients to just get them moving a tiny bit. To get them feeling confident with where they’re at. How much is needed to reduce the risk of certain cancers? We’ve kind of talked about that and I’ll go further into that. We also talked about being with a certified professional is always important because we know what we can do for them moving forward in their progression of where they’re at in the stage of their health. The special considerations that we look at when they come for an orientation. We look at their pain level, have they had surgery, is it chronic and their neuropathic. Then one of the big things we see is neuropathy. Those of you that don’t know what neuropathy is it’s the numbness and tingling usually in hands and their feet. It messes with their balance and gait issues. Trying to get them to balance on a pattern just on the floor is really difficult. We really take that into consideration because balance is super important. Muscle imbalances. If they’ve had surgeries mastectomy or any hysterectomies Those they have to cut through muscle. They cut through the nervous system. It also causes muscle imbalances, which then goes along the lines with their balance and gait. We have to be considerate of the surgeries and if they had reconstruction of how to progress them in their fitness journey. On the other main point that we look at is a range of motion. We test their range of motion. If they have limited range of motion a lot of is because of the scar of adhesions. Axillary recording if it’s a breast cancer client. Then most important we look is the cardiotoxic effect. A lot of them are on prescription or are going through chemo. We really have to take that in effect because it does affect the heart and not progressing them too fast on the cardio side. These are all the special considerations that we do through our orientation process with our clients. So, we do have a question here. Okay. Can you address your recommendation on how soon their cancer patients start an activity program? Yes, so normally depending on their surgery. If they had surgery they usually have to start with an outpatient so a physical therapist. Then that’s usually six weeks with a physical therapist. Then once they’ve gone through that process they would recommend them to phase two which is our program. If they had no surgeries or what not then they can start right away. As long as the doctor gives them go ahead. We asked for a doctor’s release saying they’re okay to exercise and if they are then they can come straight to our program. The don’t have to go through physical therapy first. That being said with the Saint Mary’s Cancer Rehabilitation Program there’s phase one and phase two. I kind of briefly described just before. Outpatient therapy, they’re working with the physical therapists and occupational therapists or some speech. Depending on where the cancer was. In my particular experience, I’ve worked with somebody that had throat cancer and they’ve totally taken out the whole side of muscle of her neck. So, I’ve really had to take two special considerations with her with her speech and just laying down on her back in general. Through this process, she got released. It is really important especially with breast cancer if they had one lymph node taken out they are at risk for lymphedema. If they had any radiation they are at risk lymphedema. They will see the specialist first to make sure that the lymphedema is controlled. They get the education and the treatment and what they need to do is we manage it. That will help reduce the risk. They get myofascial release if they did have a mastectomy so around the scarring. Trying to get more of that motor skill and the muscle balance back together before they start a exercise program. Another big thing is fatigue, when they are going through treatment or they come out of treatment. Most patients or clients are super fatigued so working with the therapist first to make sure that they are at a level to start exercising. Then they release them. Another big one is the pelvic floor dysfunction for both men and women, so I see Prostate cancer. About 90% of my clients are women with breast cancer, but I also have had two men with prostate cancer. The pelvic floor and the dysfunction is super important so that’s a big thing I focus on at least in my class. After they’re released and the therapist is good to go then they come to us. This is where they would come for their orientation and get information about our program and we get to learn about their journey and what has been going on with their health. Part of our program includes that they get two days a week with a specialists. Then they also get health coaching. The health coaching really helps with the nutrition side. Like what are they doing daily to keep them mentally healthy, physically healthy and then get them ongoing. That is free to them part of the program. The get two nutritionists appointments as well if they want more they can, but this the free part of the program. We also do massage not me particular, but we offer massage at the facility. It is just an additional thing that they can do as part of the program. Starting with a cancer specific Rehab program. Like I said, we are certified Exercise specialists. It is an advanced qualification to develop fitness professionals for higher education and to be able to work with patients during and after treatment into their survivorship. That’s what makes us more qualified than just a regular personal trainer who can definitely work with this population, but just may not have the skills to look and progress them effectively in a fitness program. It gives structure. We all write our own programming. We make sure we go with each one of our patients. We have five to ten of them. We give structure to each because patient each patient is different. Different issues and it gives them a safe environment to work in with a specialist. We do know how to progress those exercises. Depending on if they have lymphedema or if they just had surgery. All those special considerations that I talked about earlier in the presentation we all start with this progression based on where they are. Modification for limitations, we really get to build that one-on-one relationship with them. We get to know what their limitations are. So we are progressing them safely. They do have feedback on Progress. We do two initial assessments. We start with the initial one when they first come and see us. We could do their range of motion, cardio, and strength for their initial. Then we test them again at their six week mark to see where they progress. They can see about weight loss. The big goal is not to lose weight but, we really try to focus on helping them gain muscle. So, they are getting that feedback with progress. Support and encouragement. These groups are huge for all survivors. They have this special bond that really allows them not only to just come and exercise, but they also have that one-on-one time and bonding moment to share their experience. They get to enjoy the process along with others who are in survivorship. The expertise as I already kind of talked about we’re just more specialized with this population and we can carry on through that. When I was talking about with the fatigue. This is one of the things we see quite often. If they are in treatment or just coming out of treatment cancer related fatigue is really big. So, we use this skill to see where they are as far as how they’re feeling that day and how to budget their energy. if they just want to do a nice brisk or soft walk around the track. Then that’s what they’re going to do. We just really encourage more of movement a little movement goes a long ways. Even if it’s two minutes that you’re participating in the class that day it allows them to get the extra energy that they need for whatever it is that they are fighting for. Lymphedema is a bigger. They I seem like I said more in our breast cancer We do have some ovarian cancer patients as well and It’s really big to just be aware of lymphedema’s dangerous if it gets out of control. We are specialized in exercises that help with lymphedema. If they are at risk the progression is super important and how we progress our patient our clients who do have lymphedema. Most of them will wear a sleeve that also helps with the prevention depending on the severity of their lymphedema. Building community is one of the biggest parts that maybe is not so much talked about. Exercise is exercise and a bicep curl is a bicep curl. However, it’s all how we program and how we progressed our clients. Building community is probably one of the biggest pieces to this. The biggest one is their self-esteem. A lot of them after they have treatment or surgery are not feeling good about themselves. To be amongst others is very important for them to help with their survivorship and to kind of rebuild that self-esteem. Rather it’s, hey, you did one push-up and it was on the wall. It just gives them a little bit of love towards what they’re going through. The self confidence going back to surgery and treatments, they are very insecure about what has gone on and their body has changed. Just making sure that you see them as the person is super important. Then being around other survivors is really big in this process that they’re healing mentally and physically. Their strength during and after is quite remarkable. We don’t have huge stats from our program of what we see. I would say half and half are either out of treatment or in treatment. We do see at least an 86 percent of our patients and clients meeting their goals as far as strength, balance, and cardio. It is a pretty high percent of what we’re seeing with the clients that are coming to us. With our particular program on average we’re seeing about a two pound weight loss at each checkmark. No, that doesn’t sound like a lot, but we’re also fighting against… A lot of them are on hormone inhibitors, which doesn’t help with the weight loss. A lot of times they will gain weight, but as long as we can keep them building muscle and building strength it does help at least maintain what they have. Which is super important. Another thing that we see when we do a sit to stand chair for 30 seconds. We received about a 5 repetitions. Strength wise on that strength and balance were seen 5 more than what they usually do and that’s on average. Again, these are low numbers, but there’s a lot of adversities that we are against especially if they aren’t treatment. The fact that we see progression within six weeks is quite remarkable with this population. Most of all, the zest of life like they love coming and interacting with people which is so fun. That’s the most important like if their mind is good then they are going to be good. Sorry, we have one other question. While some cancer patients lose weight during and after treatment many gain from medication, steroids, and et cetera. Do you address this weight gain issue? We do not address the weight gain. Like hey Sal, you gained three pounds what is going on? We usually know that they’re on a medication. We know what they are going through. Again, like I said, our most important part is watching their fatigue. If they are higher on that fatigue level, what can we do to keep them moving? Can you sit and stand on the chair five times for one minute? We just try to progress on a slower basis The weight is such a big issue because a lot of don’t want to gain weight, but they are gaining weight because of the hormones. We address it in a positive way versus like you gain five pounds what is going on? We pretty much know why they’re gaining weight. To answer your question we try to do it in a positive aspect of what can we do to increase their strength? Would be one of the bigger ones for us to help balance that out. The best practices of care in what we are seeing is usually when a patient comes to us they have been newly diagnosed or just came out of their treatment. This is kind of the steps that they will go through. If they can do any prehabilitation they can come to us during or while they’re going through treatment. It usually helps with their outcome later on. If they have impairments this is where they would go and see a physical therapist first depending on how severe those impairments are after surgery. If it’s pretty mild then the physical therapist will usually release them. They’ll still be working with physical therapy, but also be working with us at the same time. If they’ve had no impairments then the doctor can release them straight to our program. Our ultimate goal is to get them to have general exercise and wellness through their life and give them the tools that they need to maintain a healthy lifestyle for them moving forward. Why is it 90% women? Why do you not have more men? What do you expect and think? I think one of the bigger reasons why we have women is because when this program came to Saint Mary’s it was developed around breast cancer. We started working with Moms On the Run a local breast cancer organization. They really became involved and were giving scholarships so, women were kind of the targets at that time. The certification actually rallied around breast cancer more than prostate and pancreatic cancer. We are actually starting to see more men come into the program. Not only that, but this program has not really been presented outward to make other physicians and nurses understand like any cancer person can come to or client can come to our program regardless of what cancer. Scholarship wise it’s really just breast cancer. I think that’s why we are seeing a higher number of breast cancer. With all that being said Cassy Goodman over at Saint Mary’s she is the medical fitness supervisor. If you had any additional questions about the program or would like to come into contact with myself that is the information. That is her email and phone number to get in contact with her. Saint Mary’s outpatient rehab who we work really closely with that information is there. They have two lymphedema specialists there. That’s why we work really closely. There’s actually an additional one at Renown now. So, if you’re looking for a lymphedema specialist definitely reach out to Saint Mary’s or Renown for their lymphedema specialist. Who I’m certified through and where got most of this information from is the Cancer Exercise Training Institute. It has been around since 1995. She’s been certifying all of us trainers for advanced qualification. You can go to their website and check out their great information on exercise all different types of cancer survivorship. Anything you really want to know more about. If you are looking to get certified in this that’s where you would go. A partner is Medical Fitness Network. This is a newer network who is working with medical fitness participants and trainers to get out into the field. To work with physicians and insurance companies to help everybody understand like what we’re trying to do. We’re not just trainers on the side trying to help this population. We’re actually more advanced qualified. If we can be more involved with the medical fitness side will insurance come out? They’re really trying to get bridge the gap between physicians and exercise specialists to really help this population with insurance and funds that they can’t afford this type of programming. And on that note. Do you think that there is anything that everyone can do to kind of help support getting exercise recognized as a medically covered service? That is a tough question because I think with the network now being out there. We’re getting more recognization about it. The best thing is the more educated you are about our program or what else is out there. Knowing our qualifications and knowing that we do specialize in this populations with the credentials that go behind it. Supporting us in this movement would be huge. Going to that network and just seeing the work that they are doing to try to bridge that gap between the trainers and the insurance company in the physicians to help understand that this is a good program. They’re seeing outcomes. I think that studies speak volume, so if we can get more research also in this field. We would be able to back a lot of our work that we’re doing. Are there other Fitness Centers that are doing this in Reno, that have cancer exercise specialists? No, all right now Saint Mary’s is the leading place that is doing this type of work. As an exercise trainer, I can go out to other facilities and bring this programming to them. That’s one thing I would even love to do, but as far as the structure and everything, Saint Mary’s is the only facility at this time. Yeah, I think that addresses a question that came in that asks, Are all your clients receiving treatment at Saint Mary’s? No actually Yeah, so not all of them are receiving treatment at Saint Mary’s they’re all over. We get people from Truckee and coming from Renown. It’s all over because if they come into our program they actually get a membership with the program. They have full access to our facility. They see us twice a week. They get the health coaching and nutrition, but it’s also a membership to the facility. It doesn’t matter where you live or where you are. You can join the program. Who pays? Well. Usually the… That’s where I’m talking about with bridging the gap between between insurance companies and the whole medical field. Normally it’s the client that will pay. There are scholarships available. We’ve had a couple incidents where insurance has paid and that client in particular went to their insurance company told them what they are doing. We wrote up a little document stating what we do and their insurance company actually ended up paying for the program for them. We have small movement towards the insurance area but usually, it is the client that is paying. The scholarship is only available to breast cancer patients at the time because that’s just the organization that we worked with. I know we’ve worked with Nevada Cancer Society and I believe they’ve supported and gotten a couple of scholarships as well. It’s very small. The most we see scholarships coming from is Moms On the Run and the clients are usually in treatment at the time for the scholarship. What is the cost? The cost is three hundred sixty dollars for the 6-week program. They can progress so after that six weeks if they want to stay on then they can. That’s when they work with membership and get the program as a whole. It is three hundred and sixty dollars for those six weeks and they get the full membership to the facility. They can take all the group classes. We have water aerobics, water therapy, and a lot of additional classes that they can take if they are feeling up to it. They work with specialist twice a week and they get the health coaching with nutrition part. Hi, this is June Hunter. Can I make a comment? Go ahead. Awesome. Kind of a testimonial to this program. I did go through it. Actually twice in a couple of different phases in my cancer. You know, post cancer treatment and it was vital to to my recovery. It took a long time. It took like a year and a half I went into the program, I went out of the program, then I got back into the program. So much of it as was vital to my recovery and my kind of getting back to who I was and so forth. What the program was most important to me was they knew how to take me through the program step by step. I have been exercising my whole life and so forth. I just went through this 360 kind of thing. They took me step by step like I couldn’t train the way I used to. Once I got that mindset, then I started really recovering. It’s still helping me every day. While we’re talking a lot about Reno. This needs to expand to Las Vegas and help so many people in Las Vegas. I don’t know how we can do that, but let’s look for funding or whatever that would take and really try to help more people beyond our area. Thank you. Thank you, June. I did want to say the YMCA does have their LIVESTRONG program in Las Vegas. I believe we do promote that on our website as well. That is free access to the YMCA and their LIVESTRONG program for cancer survivors. I have to say. I also went through the rehabilitation program with Christina. She was she was my cheerleader and it’s amazing. It truly is amazing. Just how it changes your mindset. Here you have been beat up just feeling horrible and it gives you so much and so much strength. It’s just a really great program. So, thank you. Thank You Carmen did you have a question or comment? Yes, and I have a comment and a question. How long has this program been working? Saint Mary’s had started five years ago. I have been apart of the program for three years. Since I’ve been apart of it, it has progressed quite a lot, actually. We’re seeing a lot more patients and clients coming in before a treatment, during treatment, after treatment, and then when they’re in treatment. We’ll see a decline and we’ll see it come back. Depending on where their treatment is. As for Saint Mary’s it has been going on for five years currently. Okay, this is a program that has a very important potential to help. My suggestion is not a suggestion. It is like a wish because from the statistical or epidemiologic point of view survival in time is the indicator that we get. I believe that this program if you can contact some medical doctors or I exactly don’t know. In order to analyze your results in time by stage at diagnosis. I believe that the early stages could help not only the best quality of life or survival, they can get more time. Yes. Then I believe that this is very important to explore these results because science is talking about the high associations between sugar and cancer. Fat and cancer. Then I believe that this program has a very high potential to give results. Thank you. Yes, thank you Carmen. So true and it would be amazing if this was something that was covered through insurance. Especially because fitness is an evidence-based preventive for recurrence of cancer and those long-term outcomes for patients. Did you have a comment, Cristina? Just another comment The University of Nevada, Reno has through their office of medical research has recently opened or expanded a clinical research center. So that might be at least here in the north that might be somewhere where we can reach out to. They’re looking to connect organizations and people with medical students to do this kind of research. As June pointed out. We need also to connect with the south, but there’s the UNLV Medical School, that’s there. There’s Turo medical schools. There are opportunities so those on the phone and us here in the room… There are connections that you can help provide then that will be beneficial for us in moving this forward. I was going to say to the numbers that I presented. Those are all through us. We just tracked them Cassie the medical supervisor she takes all the data every six weeks and we go through every patient or client that we have. We review all those numbers and she documents all this. So, it’s really not like scientific…You know? It’s just us documenting and trying to see there is a need clearly here and there is progression. We’re seeing success with it. I know Cassie has a lot more numbers than what I presented This was just based off of 2017, because she was still doing 2018 numbers. She does have pretty cool numbers to show and present just based off of the five years we’ve been doing the program. Is the best way for someone to get into the program to be referred by their physician or can anyone walk in to the fitness? If they know about the program and I believe there’s an attached flyer about our program to this presentation. You guys can print and get to your clients or to your patients. They are more than welcome to come to Saint Mary’s and check out and get more information. They’ll meet with one of the specialists and get the tour the orientation of what they’re all about. It does not have to be a physician referred they can just come in. The biggest thing is getting the word out that this program exists and it’s available to anybody that has been or is going through treatment. Even if they’re five years out of their survivorship they are still a part of this program. Is there any attrition in the program? What is attrition? It means like drop out. Oh, yeah. Drop out would be depending on if they’re in treatment. Treatment can change their trajectory of their health depending on where they’re at. Some will come if they’re in between treatment they’ll come for two that week and then I won’t see them for a week. Then if we don’t see them for a couple more weeks that’s when we reach out. If they do have to stop for their period of treatment we freeze their account so they don’t lose their time. Which is really nice, so if they’re only supposed to be here for the three weeks or the six weeks and they can’t make it we freeze it. They can come back and it basically starts where they ended. So we have that option for them. As far as drop out never coming back I don’t know those particular numbers, but I can speak from my own experience. I mainly see if they’re in treatment. That’s when I see the drop-off, but then I always will see them like a couple weeks later. The community that we build around it… I feel like I’m texting these people at this point. I’m like where are you at? How are you? Bridget can say. How are you? I’m just checking in. We just really built that one-on-one connection with our groups as well. Any other questions out there, please feel free to take yourself off mute. If you’re on video raise your hand and I can take you off mute or write in using that chat function. Any age? Yeah, any age. Sadly to say I have an 18 year old that I work with. Yes, it’s any age. Where we come into problems as we haven’t really worked with the adolescents. Like our really young population, but doesn’t mean we can’t. It really comes down to safety at the gym. I think the youngest is like 14 as long as they’re going through the orientation. There’s room for conversation there, but the youngest that I have worked with is 18. One thing I wanted to say about the gym that this is amazing as a mom. Part of the benefit of your membership is that there’s a daycare there as well. For parents that are going through treatment, they would be able to take their children and have them watch their the daycare while they work out. So, that’s a really wonderful benefit. As long as they are six months or older. Brigette, did you have any other questions? No, I don’t think so. I think you covered everything. I have one more comment. I see that someone is participating out of Elko. Just a question as to what kind of need you might see there. Are there facilities there in Elko that might be appropriate if there was someone with Cristina’s kind of training that came into your area? Sorry, I think that is Allen he helps for our IT. Oh, okay. Hi Allen! Okay, sorry. He’s like I don’t know. Is there anyone in a rural area though that could benefit from Cristina coming out and doing her program? *Laughing* Could you speak about that? Are you there? Do we have audio for you today? There’s Vegas. We have Sunrise. There is another question here. Does a doctor prescribe them to come to your program? It’s a good question, because as a prescribed scenario you would think insurance would cover something that was prescribed from their physician. The one way we’ve been able to kind of work around this and Cassie can kind of speak more to it. We talked to the insurance company and we compared it to a cardiac rehab. Like what they are doing in cardiac rehab. When they’re released from their physician, that’s basically what they’re doing in our phase two program. They are supervised by a specialist and at that point that’s when insurance… As long as they have like a really good description of what we were doing their insurance followed. The other way some of our patients are paying for the program is through their health savings account if they have that. We’re along the lines with acupuncture and massage. We kind of fall into that category. If people are using their health savings account for those things they can use it for this particular program as well. Yeah, it gets me thinking about like a lot of the wellness programs that a lot of employers are trying to get people to get up, get moving, get your steps, etc. So, I wonder if that might be kind of a… It’s a gateway. Just because it’s a specific population it’s a big population. You would think it would be something that insurance company would take a bigger look at it. But again, I think it comes down to funding for research too because numbers speak and if they’re seen progression here, then there’s a possibility that this can be covered by insurance. If your goal of your treatments so expensive. Three hundred and sixty dollars may not be a lot to some, but it’s a lot. Especially to some of the older population if they are on a budget they’re retired. That’s where we kind of see the hard stuff. Any other questions as we start to wrap up here? Thank you so much, Christina. I just have to say I am so excited about this whole series. Just the information as well as with everyone being able to put their heads together and see this as such a need in the community. You guys are just doing such amazing work. Thank you. One thing I wanted to say is please mark your calendars. We have our upcoming Nevada Cancer Control Summit, which is on September 16th, 2019. It’s a one-day statewide conference featuring presentations on targeted topics across the cancer spectrum. We’re gonna have a lot of wonderful speakers at this conference this year. If you would like to learn more, please do go to our website. You will see some more information and you can I believe register early as well. Our next clinic in the series is on February 22nd at 8 a.m. To 9 a.m. The topic is on survivors of childhood cancer. The presenter is going to be Doctor Robert Raphael, he’s an Associate Hematology Oncology Medical Director at UCSF Benioff Children’s Hospital in Oakland. He will be calling in remotely and we are very grateful. Thank you so much, everyone, for joining us today. Thanks, everyone. We hope to see you in a couple weeks. Thank you.