Exercise after Breast Cancer

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Exercise after Breast
Cancer: Promoting a
Healthy, Happy Recovery
Joy Kiviat, PhD, MSN, RN
Oncology Certified Nurse
University of Arizona College of Nursing
ACSM certified Cancer Exercise Trainer
and Group Exercise Instructor
Educational Objectives
Participants will:
 describe specific health benefits of exercise
for the breast cancer survivor
 evaluate research findings on safety and
efficacy of exercise
 recognize need for providers to discuss
exercise with cancer patients
 state appropriate goals for aerobic and
resistance exercise duration and intensity
 identify local and regional exercise
Cancer & Exercise
Research indicates that cancer
patients who exercise:
 report less fatigue
 require fewer blood transfusions
 are hospitalized less frequently
are less likely to fall
have better outcomes and improved sense
of well-being
Consensus: Exercise is Beneficial,
During and After Cancer Treatment
2012: American Cancer Society guidelines for
nutrition and physical activity strongly support
exercise as an important part of survivorship
care planning (Rock et al., 2012).
Exercise promotes Recovery,
• Reduces overall mortality among survivors
• Evidence is mounting that moderate activity
and a healthy weight can help prevent
cancer recurrence
• Strongest evidence in breast and colon cancer;
recent studies suggest exercise reduces risk for
prostate and brain cancer recurrence too.
(Loprinzi et al., 2012; Pekmezi & Demark-Wahnefried, 2011)
How does exercise help?
• Increased lean body mass, decreased fat
• Improved cardiovascular condition (lowers
risk of embolism, heart attack and stroke)
• Increased bone density and improved
balance (reduces risk of falls and injury)
• Immune system stimulation (reduces risk for
infection and recurrence)
• Release of endorphins and other stimulatory
neurotransmitters (elevates mood)
Improving Balance
Body Fat & Cancer-What’s the link?
Higher energy (calorie) intake leads to:
↑ Insulin & insulin-related growth factors
↑ Free Estrogen & Androgens
↑ Leptin, ↓adiponectin =>↑ tumor growth
↑ Inflammatory chemical messengers
Result: more fuel available for cancer cell
growth, excess hormones, and weaker
immune response to abnormal cells
Source: Annual Report to the Nation on the status of cancer, 1975-2008, featuring
cancers associated with excess weight and lack of sufficient physical activity.
(CDC, 2012)
How do we know?
2009 Study: Patients treated for breast cancer enrolled in 12
weeks aerobic and strength training exercise – compared to
“usual care” they had significant gains in fitness, strength,
lean body mass, and overall quality of life. (Rogers et al., 2009)
2011 Review of 21 RCTs showed exercise is safe for cancer
survivors, and improves physical fitness and psychosocial
well-being (Pekmezi & Demark-Wahnefried, 2011).
2012 Systematic review: 27 high quality studies of activity
and cancer outcomes showed consistent evidence of
reduced cancer-related mortality and improved biomarker
and immunity profiles.((Ballard-Barbash et al., 2012)
Overcoming Barriers
• Provider education: most oncologists
aware of exercise benefits, but primary
care providers may not be informed*.
• Exercise prescription pads for oncologists
• Include exercise in Survivor Care Plan
• Patient education: convince survivors of
immediate and long-term benefits
• Community presentations, brochures
*Sabatino et al. (2007)
Increased Flexibility
Common Concerns
of Survivors
• Fatigue: Just want to rest…
• Safety: Am I ready to exercise?
• Could I get injured, will this interfere with
recovery, risk for infection…many concerns
• Cost: fitness center membership, personal
trainers, may be out of reach for some
• Access: location, transportation, time of
day…..What do YOU recommend?
Addressing Concerns
Readiness test
Exercise Readiness Test*
Answer yes or no to the following questions:
• Has your doctor ever said that you have a heart condition and that
you should only do physical activity recommended by a doctor?
• Do you feel pain in your chest when you do physical activity?
• In the past month, have you had chest pain when you were not
doing physical activity?
• Do you lose your balance because of dizziness or do you ever lose
• Do you have a bone or joint problem that could be made worse by a
change in your physical activity?
• Is your doctor currently prescribing drugs (for example, water pills)
for your blood pressure or heart condition?
• Do you know of any other reason why you should not do physical
*Adapted from Physical Activity Readiness Questionnaire (PAR-Q)
developed by the British Columbia Ministry of Health & Multidisciplinary
Board on Exercise
Readiness Results
If you answered yes to any question:
• consult a physician before increasing physical activity
• ask for a medical clearance and any exercise limitations
• in most cases, you will still be able to do any type of
activity you want as long as you adhere to some
If you answered no to all:
• you can be confident that you can exercise safely
• It is still important to start slow, increase gradually
What about Lymphedema?
• Recent study showed upper body resistance exercise
does not increase swelling and was associated with 50%
decrease in exacerbations (Schmitz et al., 2009)
141 women with stable lymphedema and no previous hx
of weightlifting, randomized to 2x/wk weight training or
control group for 1 year
• NLN 2011 guidelines: Start with low resistance,
incremental increase with regular measurements; advise
compression garment if lymphedema already present
• No controlled studies on value of compression garments
during exercise for prevention of lymphedema
Exercise Options
Group classes (YMCA, community centers, fitness
Personal trainer (some make house calls)
Walking (suggest finding walking buddy or dog for
companionship and motivation
Swimming (good for persons with joint or bone pain)
Exercise videos and FitTV channel
Better than Ever program at UACancer Center
How Much is Enough?
ACS & ACSM roundtable concluded cancer
survivors should strive for:
• 150 minutes/week aerobic exercise
(aim for 30 minutes, 5 days a week;
try brisk walk, run, swim, dance)
• 2-3 sessions/week resistance exercise
(weights, bands, water bottles…
1-2 days off between sessions)
• Daily stretching/toning
Source: Schmitz et al., 2010
Ballard-Barbash, R., Friedenreich, C., Courneya, K., Sameer, M., Siddiqi, S.,
McTiernan, A. & Alfano, C. (2012). Physical activity, biomarkers, and
disease outcomes in cancer survivors: A systematic review. Journal of the
National Cancer Institute 104(11): 815-840 doi:10.1093/jnci/djs207
Irwin, M. (2008). Physical activity interventions for cancer survivors. British
Journal of Sports Medicine 32(8) 32-38. doi:10.1136/ bjsm.2008.053843
Loprinzi, P., Cardinal,B., Winters-stone, K., Smit,E. & Loprinzi, C. (2012)
Physical activity and the risk of breast cancer recurrence: A literature
review. Oncology Nursing Forum 39(9) 269-74.
Pekmezi, D. W., & Demark-Wahnefried, W. (2011). Updated evidence in
support of diet and exercise interventions in cancer survivors. Acta Oncol,
50(2), 167-178. doi: 10.3109/0284186X.2010.529822
Rausch, S., Millay, S., Scott, C.,Pruthi, S., Clark, M., Patten, C., ….Vachon, C.
(2012). Health behaviors among cancer survivors receiving screening
mammography. American Journal of Clinical Oncology. 35(1), 22-31.
References, cont.
Rock,C.L., Doyle,C., Demark-Wahnefried,W., Meyerhardt, J., Courneya,K. S.,
Schwartz, A. L., Bandera, E. V., …, & Gansler,T. (2012), Nutrition and
physical activity guidelines for cancer survivors. CA: A Cancer Journal for
Clinicians. doi: 10.3322/caac.21142
Rogers, L., Hopkins-Price ,P., Vicari,S., Pamenter,R., Courneya,K., Markwell
,S., … Lowy, M. (2009). A randomized trial to increase physical activity in
breast cancer survivors. Medical Science Sports Exercise 41(4), 935-46.
Sabatino, S., Coates, R., Uhler R., Pollack, L., Alley, L., & Zauderer, L. (2007).
Provider counseling about health behaviors among cancer survivors in the
United States. Journal of Clinical Oncology 25(15) 2100-2106.
Schmitz, K., Courneya, K., Matthews, C, Demark-Wahnefried, W, Galvao,
D.,…, & Schwartz, A. (2010). American College of Sports Medicine
Roundtable on Exercise Guidelines for Cancer Survivors. Medicine &
Science in Sports & Exercise 42, 1409–1426.
Schmitz,K., Ahmed,R., Troxel,A.,Cheville,A., Smith,R., Lewis-Grant,L.,
Bryan,C., Williams-Smith,C., & Greene,Q. (2009). Weight lifting in women
with breast-cancer–related lymphedema. New England Journal of Medicine

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