Cancer sufferers used to be told to avoid exercise and eat what they could stomach. Surgery, chemotherapy and radiography knock the body around and doctors didn't want their weakened patients doing fun runs or forcing down steamed fish.
Lina Pugliano believes they got it wrong. The Sydney oncologist is pioneering a new form of cancer care that starts in a fitness centre. Her fitness centre.
The idea's genesis came from her personal trainer, Rob Wen. Pugliano was venting one day to him about the way many cancer patients stopped or ignored physical exercise during their treatment. "You need to start a boot camp!" he told her.
She agreed. Almost four years later what started as an almost ad hoc training session for her patients under Sydney Harbour Bridge has evolved into a surprisingly innovative approach to cancer treatment. Not only is Pugliano doing good medicine, the 41-year-old third-generation Italian immigrant is demonstrating that doctors can make good entrepreneurs too.
"I would come home all the time and say: 'This is frustrating. There is nowhere to send patients,'" Lina Pugliano says. Peter Braig
Salmon envy
We meet at Pugliano's choice for lunch: Chiswick, a low-slung Woollahra dining institution that would feel at home on the River Thames. After surveying the menu she says she'd love the salmon, which comes with persimmon, an Asian fruit, and rocket salad. But she is pregnant [baby Puglioano arrived on September 26] and asking for a well-done salmon fillet would be a culinary crime, Pugliano says.
Instead, she selects the barramundi, which is safely poached in a baking paper bag with broadbeans and peas. Being without child, I selfishly order the salmon, which is deliciously crispy on top and soft inside.
For privacy, we choose a high wooden bench table, away from the other diners, that overlooks the restaurant's kitchen garden.
Pugliano is nervous. Who can blame her? Like most medical specialists she has spent her career and training in the intense and closeted medical world. She hasn't been interviewed before, she admits. She's used to being in charge. Being on the other end of a reporter's tape recorder places her in an atypically vulnerable position.
Pugliano gravitated to treating breast cancer, a disease with a 90 per cent survival rate.
Pugliano chooses not to drink and out of solidarity I stick with the sparkling water the waitress has brought to our table, and doesn't charge us for.
The barramundi looks excellent, and she holds a piece up so I can get a closer look.
Becoming a physician
Pugliano attended a small, safe Catholic high school in Manly on Sydney's northern beaches. In a society framed by low-level xenophobia, the family didn't embrace their heritage and despite her name, Pugliano can't speak Italian.
"When you're a medical student the patient knows more than you," Lina Pugliano says. Peter Braig
She initially missed out on medicine, but through diligence and a knack for science was admitted to medical school in her early 20s. Lacking the ability to conceptualise hand movements in three dimensions, surgery was out. She decided being a physician would be more interesting anyway. But what type?
Sydney University medical students spend time once a week with tutors who are practising doctors. One of hers treated cancer patients. Introduced to the oncology ward Pugliano felt something kick in – a natural desire to help the sick, which isn't a universal trait among medical professionals: a Sydney plastic surgeon was reprimanded for going ahead with a breast implant in 2015 after his patient suffered a minor heart attack on the operating table.
Enjoying the cancer ward
A big part of the job was extracting information from patients, from the profound to the practical. An individual's financial resources can play a role in their recovery. Their social network can impact their morale through the rigours of chemotherapy.
About 50 per cent of the centre is a gym. There are no mirrors on the walls and a lack of ego on the machines.cancerfitaustralia.com.au
"When you're a medical student the patient knows more than you," Pugliano says. "But I think I can listen very well."
In a ward where people were dying and surviving, Pugliano was fascinated by the challenge of trying to defeat tumours consuming their hosts from inside.
"I really enjoyed it because it started to mould what I wanted to be as a doctor," she says. "Technically it was very interesting. There is more to it. Their lives, how they're affected ... the impact in social surroundings.
"The perception from the outside, driven by movies and the media, is there is a lot of sadness there. There is a lot of positivity too. There is always something we can do for someone."
"We try to be positive. We try to make this about having fun exercise and healthy lifestyles," says Lina Pugliano, about her gym for cancer sufferers. Peter Braig
Sub-specialists
Medicine has become so sophisticated that specialities have devolved into sub-
specialities. Within oncology, many or most urban physicians work on only one or two tumour types - that is, different forms of cancer. In many country areas, oncologists don't have that luxury.
After finishing her oncology training, Pugliano worked for two years at Jules Bordet Institute, a cancer hospital in the Belgian capital, Brussels.
With an innate feeling for the vulnerability of the human mind, she gravitated towards breast cancer. Overwhelmingly but not exclusively a disease suffered by women, breast cancer has a 90 per cent survival rate. But the disease often has profound psychological effects. A woman diagnosed with breast cancer may not be unwell. They may not even be able to detect a tumour.
"They came in [for a diagnosis] and they felt normal," Pugliano says. "You have just ripped the world out from under them."
Within weeks or months they could lose their energy, hair, eyelashes, eyebrows and muscle tone. They can go from healthy to overweight. Their breasts may be surgically removed. They may lose the ability to conceive.
A chance to plan
In a society that judges women on body image, breast cancer extracts a high cost. As compassionate as she is, Pugliano wants patients to know what is coming. The dying deserve a chance to plan. She is direct.
"It doesn't suit anybody to beat around the bush," she says. "They need to know what's coming their way and what that means."
Like many dedicated professionals, Pugliano uses exercise to relieve stress. She runs and lifts weights. She loves the gym. Pregnancy hasn't stopped her staying fit. "Being strong is very empowering and is good for psychological wellbeing," she says.
She hired a personal trainer, Rob Wen, and fell in love with him. They married: "We didn't like each other when we first met. It took a while."
The waitress clears our empty plates. A dessert menu appears. I eye off the lemon tart, which comes with rhubarb.
Pugliano demurs. The discussion about healthy lifestyles makes dessert an awkward choice. Wistfully, I hand the menu back and turn to the intricacies of post-operative cancer complications.
Don't avoid weights
Often the lymph nodes in a woman's armpits are removed as part of a mastectomy. After surgery many doctors advise their patients to avoid heavy lifting because of a perception that it will cause lymph fluid to build up in the hands, arms and other body parts, causing swelling.
Although such advice sounds benign, it can badly disrupt the lives of women being treated for cancer. Housework and caring for young children becomes problematic. Even driving can be out.
Pugliano advised women to go slower, but not too slow. "People were being told, 'You should rest, take it easy, put your feet up, eat what you can,'" she says.
Obese women have a higher chance of their cancer tumours returning, medical studies
found. Other research suggested that fitness played a role in the success of treatment, and that weight lifting after breast cancer surgery might lower the risk of swelling. "I started seeing some of the information," she says.
Frustrated
Pugliano, who helps train breast cancer oncologists in Sydney, became convinced that maintaining physical and psychological fitness during treatment was an important and under-emphasised factor in patients' recoveries.
Reaching a conclusion was one thing. Putting it into practice was very different. She couldn't unleash them on the nearest Fitness First gym. Very sick people needed medical supervision.
"I would come home all the time and say: 'This is frustrating. There is nowhere to send patients,'" she says.
Out of that frustration, boot camp was born. In a park under the northern end of the Sydney Harbour Bridge, Pugliano and her husband began a weekly fitness class for her breast cancer patients. Some women going through chemotherapy were so weak they needed help walking up the park's hill.
Soon, Pugliano could see a difference. "It changed them," she says, a hint of pride slipping into her voice. "It had a great impact on their ability to get through treatment."
After 18 months, Pugliano decided she wanted to turn a free service for a relatively small group of patients into a financially sustainable operation that could help far more people.
After another year and a half, Cancer Fit Australia was born - a cross between a gymnasium and medical consulting rooms. Pugliano leased part of a commercial building in Greenwich, a suburb on Sydney's lower north shore close to several hospitals where she and other oncologists worked.
The physical location was important. She didn't want Cancer Fit based in or next to a hospital because she knew patients would suffer dread-inducing flashbacks to their primary treatment. But it had to be close enough for people to be able to combine treatment with a visit.
"It's really important that it doesn't look like a clinic," Pugliano says. "We try to be positive. We try to make this about having fun exercise and healthy lifestyles."
A cancer gym
The foyer, which is bathed in natural light, looks like a cross between an office and hotel lobby. About 50 per cent of the centre is a gym – a gym for people with cancer. There are no mirrors on the walls and a lack of ego on the machines. "Nobody thinks twice if you have a wig on or no hair," she says.
Finding the exercise equipment was easy. It was hard assembling a team of experts who could keep patients healthy during and after they underwent chemotherapy, radiation therapy or surgery.
Pugliano sought out expert physical trainers, an oncology psychologist, a cancer dietician and nutritionist, a cardiac ultrasonographer, a rehabilitation pain physician and other specialists, including yoga and pilates teachers.
She resolved to see every patient in person. She also insisted each have their heart rate and blood pressure tested before and after every workout. Every test taken by a patient during their treatment is available to the specialists.
A common side-effect of cancer treatments is cardiac toxicity. The drugs designed to kill a tumour may damage cells around the heart, weakening it. That makes exercise more risky for cancer sufferers, and is why their workout routines are overseen by a cardiologist.
Cancer Fit opened in August last year. In addition to helping people, the centre operates as a real-life science experiment. Pugliano plans to gather data from Cancer Fit's clients to demonstrate the benefits of supervised exercise, diets and psychological support to
cancer sufferers.
It's not a cure for cancer, but it could be one step closer.
The bill
Chiswick, 65 Ocean Street, Woollahra
1 barramundi, $36
1 king salmon, $38
Total $74
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This article was published and provided by the Australian Financial Review.