Bringing Cancer Research into the Home: Rethinking Trial Design Around the Patient

This Clinician’s View is written by AdventHealth Translational Research Associate Investigator Justin Brown, PhD.

My journey into cancer research began at home.

In 2002, when I was 14, my father was diagnosed with colon cancer. He completed his frontline treatment only to have the cancer return a few years later. When he asked his physician what he could do to improve his odds, the answer was bleak: “Show up to your appointments on time and go home and get your affairs in order.”

Eight months later, he died at home.

Twenty years ago, there was a lack of recognition that the things patients do outside the walls of a cancer center can have a profound impact on how they feel, function and survive. This, along with the recognition that anywhere from 1/3 to 1/2 of all cancer deaths in the U.S. can be traced back to some type of modifiable lifestyle factor, fueled my pursuit of a career in cancer research.

A large portion of my work for the last decade and a half has focused on the impact of exercise on cancer biology. Thanks to groundbreaking research like the recently published CHALLENGE trial, we now have evidence that colon cancer patients who were randomized to a three-year supervised exercise program reduced their risk of cancer recurrence by 28% and death by 37%. Still, questions remain:

• How does physical activity reduce cancer recurrence and mortality?
• How do we engage oncology patients in these health promoting behaviors?

That is the focus of my research today.

Conducting exercise studies with cancer patients comes with inherent challenges though, especially in terms of recruitment. If you can’t effectively recruit participants and deliver your intervention with a high degree of fidelity, nothing else matters. What I’ve learned in my time of doing this work and what we are now implementing at the AdventHealth is what I believe may be the missing secret ingredient: bringing exercise interventions directly into the patient’s home.

Overcoming Obstacles to Participation in Exercise Studies

When it comes to performing exercise-related research with cancer patients, the philosophy of “if you build it, they will come” doesn't work. If you build a gym in a cancer center, oncology patients will not show up. Not because they don’t care. Not because they aren’t motivated. But because there is a tremendous amount of time toxicity associated with going somewhere to do the exercise.

It’s getting dressed, driving through traffic, finding parking, walking across campus, exercising, reversing the whole process and finally getting home. A 30-minute exercise routine soon becomes an entire morning adventure that cancer patients simply don't have the time or energy to do, let alone do it three to five days a week.

Time isn’t the only obstacle study participants face. When I was working on my dissertation in Philadelphia, I thought I had found the perfect solution: providing patients with wearable tracking devices so that they could exercise in their own neighborhoods. However, I quickly learned that this approach came with its own set of challenges, including inclement weather and concerns about exercising outside in unsafe neighborhoods. I was getting closer to cracking the code but still hadn’t found the right recipe for success.

Providing Exercise Equipment in the Home: An Investment in Research and Lifelong Health

Then we asked a simple question: What if we stopped asking patients to come to us?

When people are sick, they want to be home. So instead of building bigger facilities, we invested differently. We deliver treadmills, stationary cycles or ellipticals directly into participants’ homes — along with wearable monitoring devices. We set everything up. We track everything remotely. And when the study ends, the equipment stays.

This solution is more than ensuring adequate recruitment and participation in our studies, it is an investment we make in each patient’s lifelong health.

Our study participants can objectively track their heart rates along with the length of their exercise, and on our end, we can pull up everything we need to know on a dashboard. This gives us objective confirmation that participants completed the exercise as prescribed, the gold standard for research quality. It also nearly eliminates the time toxicity and transportation barriers patients would otherwise face. Furthermore, participants gain the flexibility to implement the exercise program in a way that works for them. If they want to walk on their treadmill at 2:00 am in their pajamas, they can do that.

Additionally, our study participants meet virtually with certified cancer exercise trainers every week. So, we don’t simply give them a bunch of tools and expect them to figure it out on their own. They have access to expertise that teaches them how to integrate those tools into their everyday lives along with instruction on overcoming any challenges they may encounter along the way. As a result, when the study is done, each participant has gained the knowledge, skills, abilities and resources to keep exercising for the rest of their life.

Our Current Studies: Innovation in Action

This home-based exercise model is powering two of our active clinical trials:

• Adaptive Randomization of Aerobic Exercise During Chemotherapy in Colon Cancer (NCT05773144) -- The purpose of this research study is to determine if different durations of exercise can improve how well patients tolerate chemotherapy for colon cancer. Our hypothesis is that patients who exercise during chemotherapy will have less toxicity and side effects, and as a result, their oncologist will be able to provide them the full, planned amount of chemotherapy. Everything for this study is done remotely with no in-person patient visits required.
• Effects of Aerobic Exercise on Skeletal Muscle Remodeling in Colorectal Cancer (NCT05789433) -- Also known as RESTORE, the purpose of this research study is to determine how different types of exercise change muscle tissue among people who have been diagnosed with colorectal cancer. By the nature of the hypothesis we’re testing for this study, we can’t digitize everything. Patients must come to our brick and mortar building for some testing, but they can do all the exercise at home.

I’m also excited to announce that we just received a $1.5 million Casey DeSantis Florida Cancer Innovation Fund grant through the Florida Department of Health to implement a new statewide study titled A Decentralized Digital Trial of Exercise for Cancer Patients in All of Florida. The purpose of this research study is to determine if exercise can improve treatment for patients with gastrointestinal and lung cancer. The entire study is completed at home. This study is open to any Florida resident, regardless of where they receive cancer treatment, enabling all of Florida to benefit from AdventHealth’s innovative investigator-initiated clinical trial portfolio.

Putting Patients First

Too often, patient experience becomes an afterthought in research and is only addressed when enrollment lags or dropouts rise. We have flipped that model. Every decision starts with the patient:

• Where are they on their journey?
• What barriers are they facing?
• What would make this sustainable?

We’re proving that the science doesn’t suffer when you prioritize human connection and shared humanity. In fact, it gets stronger.

Dolores, one of my former study participants, lived in a high-crime neighborhood. When her trial was ending, she started crying and shared that the treadmill we provided made her feel free for the first time in 35 years because she could improve her health in the comfort of her own home.

Another participant from nearly a decade ago still emails me quarterly to share her treadmill mileage, which is now in the thousands. She jokes that she has walked halfway to California and back.

Improving Healthcare Value

Yes, treadmills, stationary cycles and elliptical machines aren’t cheap. However, innovation isn’t about minimizing cost, it’s about maximizing value.

By eliminating time and transportation barriers, we are enrolling more diverse participants and beginning to chip away at equity issues. As a result, our findings are more likely to reflect the real-world population, our conclusions are more generalizable, and our impact is broader.

Most importantly, giving cancer patients this exercise equipment and instruction is not simply a short-term bridge to collect our data and parachute out. Thanks to studies like the CHALLENGE trial, we know that we are making an even greater investment in cancer patients’ long-term health and survival while also empowering them to feel like they are active contributors in the fight for their own lives.

Shaping the Future of Cancer Research

At AdventHealth, we are committed to expanding what is possible to help cancer patients live longer, healthier lives, and bringing cancer exercise research trials into the home is an essential component. We’ve also assembled the ingredients for something truly special:

• A large Cancer Institute abundant with patients who seem to be ready, able and willing to enroll in clinical trials
• Robust physical and intellectual infrastructure
• Colleagues committed to innovation and the type of research we are leading
• A pipeline for training the next generation of scientists

I currently mentor two postdoctoral researchers with independent funding from the American Cancer Society. This is attracting bold thinkers to Orlando who are helping our patients as we move science forward.

Good things take time, but we are building momentum. Our team is doing more than just studying exercise, we’re reducing barriers, we’re expanding access, and we’re giving cancer patients something my father never had -- hope and agency from the comfort of their home.