October 2018 Issue

Focus on Fitness: Exercise for Breast Cancer Survivors
By Jennifer Van Pelt, MA
Today's Dietitian
Vol. 20, No. 10, P. 54

October is National Breast Cancer Awareness Month, which was established to increase awareness of the importance of regular breast cancer screenings to detect cancer in its earliest stages. During this month, lifestyle changes, such as regular exercise, often are emphasized for reducing risk. Unfortunately, awareness efforts often exclude breast cancer survivors in their emphasis on primary prevention. According to the National Cancer Institute, as of January 2016, there were 3.6 million breast cancer survivors in the United States. This month, I'd like to focus on the importance of exercising after breast cancer treatment and appropriate exercises for clients who are breast cancer survivors.

In 2012, the American Cancer Society (ACS) published guidelines for exercising after cancer treatment, noting that "a program of regular physical activity is essential to aid in the process of recovery and improve fitness."1 These activity recommendations incorporated those by an American College of Sports Medicine (ACSM) panel convened in 2010 to establish exercise guidelines for cancer survivors.2 Both the ACSM and ACS recommend returning to normal physical activity as soon as possible and following general exercise guidelines established by the ACSM and American Heart Association for weekly physical activity when possible—at least 150 minutes of moderate-intensity aerobic exercise or 75 minutes of vigorous-intensity aerobic exercise (or a combination of the two), plus at least two days of resistance exercise and appropriate stretching after exercising.

The benefits of regular exercise for breast cancer survivors are many, including improvements in cardiovascular fitness, strength, balance, body weight, fatigue, anxiety, depression, self-esteem, happiness, and quality of life. The ACS notes that physically active breast cancer survivors have a lower risk of recurrence and have better survival rates than inactive survivors. Resuming or increasing exercise after treatment as soon as the survivor is able is important because breast cancer treatment can take a toll on the body—no matter how fit the patient is before treatment. Depending on the type of treatment, breast cancer survivors may have impaired cardiopulmonary fitness, elevated or very low body weight, reduced upper-body function and strength, muscle weakness, balance problems, and/or bone loss.1,3 Breast cancer survivors may, therefore, have limitations specific to their treatment, and exercise must be adapted to address treatment aftereffects. For instance, a mastectomy (single or double) or surgery to remove tumors affects both upper body musculature strength and range of motion. Survivors who have had lymph nodes removed as part of surgery are at risk of lymphedema, swelling in the arms that results from a blockage in the drainage of the lymphatic system caused by lymph node removal. The ACS guideline addresses these posttreatment issues and provides recommendations for modifying exercise after breast cancer treatment.1

Breast cancer survivors who underwent surgery previously were advised not to perform any upper body resistance training or vigorous aerobic exercise. However, research on the causes, prevention, and rehabilitation of lymphedema has since revealed that earlier upper body exercise for these survivors is safe and decreases the risk and severity of lymphedema.4 The ACS recommends progressive resistance exercise, initially under the supervision of an experienced lymphedema therapist, performed while wearing specially designed lymphedema compression garments. Overweight and obesity are major risk factors for developing lymphedema; hence, aerobic exercise appropriate for the survivor's fitness level and postsurgical condition also is recommended for weight loss.1

Survivors who underwent surgery also may develop postmastectomy syndrome, a type of chronic neuropathic pain disorder that can occur following breast cancer surgery that removes tissue in the upper outer breast and armpit. This condition also can affect lung function. Recent research suggests that aquatic exercise (aqua aerobics or swimming) and Pilates, combined with initial supervised physical therapy and specialized upper body exercises, can improve lung issues and reduce pain associated with postmastectomy syndrome.5,6

Breast cancer survivors who underwent chemotherapy and/or radiation therapy often have lingering fatigue, weakness, a compromised immune system, and/or nutritional issues. According to the ACS guideline, exercise should be adapted as follows to avoid posttreatment complications.1 Special considerations may be necessary if your client has any of the following conditions:

  • Severe anemia: Delay exercise other than daily living activities until anemia is resolved.
  • Irradiated skin issues: Avoid chlorine exposure in pools, and stick with land exercise until skin heals.
  • Compromised immune function: Avoid public gyms, pools, and other public areas with potential microbial exposure (eg, ocean water) until white blood cell counts return to safe levels.
  • Indwelling catheters or feeding tubes: Avoid pool, lake, or ocean water and other settings where microbial exposure could result in an infection. Also avoid strength training of muscles in the areas of the catheter or tube. Low-impact aerobic exercises such as walking and dancing are good choices.
  • Severe fatigue: Encourage 10 minutes of low-intensity exercise daily until fatigue resolves. Water aerobics and water walking are good options if the client isn't prohibited from going into a pool.
  • Multiple or uncontrolled comorbidities (eg, diabetes, heart disease): Modify exercise in accordance with guidelines for the comorbidities under direction from a physician.
  • Peripheral neuropathies or ataxia that affects limb strength and balance: Adapt exercise to avoid risk of falls (eg, recumbent cycle instead of a treadmill, water exercise for body support).

One key type of exercise—mind-body—isn't included in the ACS exercise guidelines. Many research studies supporting the benefits of yoga, tai chi, and qigong for breast cancer survivors have been published since the 2012 release of the ACS guideline. Benefits found in these studies include improved balance, bone density, upper body strength and mobility, sleep quality, and overall quality of life, as well as decreased fatigue, anxiety, and depression. Too numerous to cite here, these studies can be found using the key words "breast cancer survivor" and "yoga," "tai chi," or "qigong" on PubMed.

Yoga (restorative, gentle, chair), qigong, or simplified tai chi are all good exercises for breast cancer survivors, even those at a low fitness level. Deep breathing and gentle movements/stretches provide cardiopulmonary, balance/coordination, and strength/mobility conditioning that will help survivors progress gently toward a fitness level where they can increase daily exercise duration and intensity level. Continuing these mind-body exercises along with more intense aerobic and resistance training will help not only with flexibility and balance but also with anxiety, depression, and stress.

Exercise resources for breast cancer survivors include the following books and DVDs:

  • Strength & Courage: Exercises for Breast Cancer Survivors DVD (www.strengthandcourage.net)
  • Yoga for Breast Cancer Survivors and Patients by Jimmy Kwok
  • Pilates for Breast Cancer Survivors: A Guide to Recovery, Healing, and Wellness by Naomi Aaronson, MA, OTR/L, CHT, CPI, CET, and Ann Marie Turo, OTR/L
  • Qigong for Cancer: Exercises for Healing and Prevention DVD

— Jennifer Van Pelt, MA, is a certified group fitness instructor and health care researcher in the Lancaster, Pennsylvania, area.

1. Rock CL, Doyle C, Demark-Wahnefried W, et al. Nutrition and physical activity guidelines for cancer survivors. CA Cancer J Clin. 2012;62(4):243-274.

2. Schmitz KH, Courneya KS, Matthews C, et al. American College of Sports Medicine roundtable on exercise guidelines for cancer survivors. Med Sci Sports Exerc. 2010;42(7):1409-1426.

3. Dieli-Conwright CM, Orozco BZ. Exercise after breast cancer treatment: current perspectives. Breast Cancer (Dove Med Press). 2015;7:353-362.

4. Stuiver MM, ten Tusscher MR, Agasi-Idenburg CS, Lucas C, Aaronson NK, Bossuyt PM. Conservative interventions for preventing clinically detectable upper-limb lymphoedema in patients who are at risk of developing lymphoedema after breast cancer therapy. Cochrane Database Syst Rev. 2015;(2):CD009765.

5. Odinets T, Briskin Y, Pityn M. Effect of individualized physical rehabilitation programs on respiratory function in women with post-mastectomy syndrome [published online February 26, 2018]. Physiother Theory Pract. doi: 10.1080/09593985.2018.1444117.

6. Exercises after breast cancer surgery. American Cancer Society website. https://www.cancer.org/cancer/breast-cancer/treatment/surgery-for-breast-cancer/exercises-after-breast-cancer-surgery.html. Updated September 13, 2017.