Breast-cancer survivors begin to challenge exercise taboos

In brief

The collaborative effort by specialists in exercise physiology, sports medicine, oncology, cardiology, psychology and rehabilitation medicine aims to determine these patients' recovery patterns related to cardiovascular fitness, pulmonary function, anaerobic capacity, strength and body-fat composition. Funding is being provided by the University Hospital Foundation's Pacific Spirit Run.

Dr. Urve Kuusk, a general surgeon with the BC Cancer Agency and one of the project investigators, describes the studies as "very innovative." Kuusk, who sees about 200 newly diagnosed breast-cancer patients each year, hopes that the projects will promote the idea of "getting women back to normal activity following breast-cancer treatment, without fear."

There are about two million survivors of breast cancer in North America, but in spite of the large number they often receive little informed advice regarding a return to exercise and sports once a course of treatment is completed. Because of a lack of research about the post-treatment phase, physicians tend to err on the side of caution when advising patients, Kuusk said. "The dogmas entrenched from the 1950s and '60s, of never do this and never do that, are pretty life limiting."

Sherri Niesen, a physiotherapist and PhD candidate who was instrumental in initiating the projects, adds: "Women are often told that they can't lift more than 10 pounds and shouldn't do any repetitive movements, including paddling [see sidebar]. We want to show women that, within reason, there are no limitations any more." Cardiac rehabilitation has only developed in the past 15-20 years and is now gaining acceptance, she notes, and breast-cancer rehabilitation may follow suit.

The primary fear about vigorous exercise has been that women whose lymph nodes have been removed will experience lymphedema. In the past 10 to 15 years, Kuusk says, surgeons have become more cautious in excising lymph nodes, thus lessening the chance of swelling in the affected arm.

Although there appears to be a correlation between the number of nodes removed and the amount of lymphedema, and it is thought that radiation of the axilla increases the risk of swelling in the arm, the causes of lymphedema are not well understood. Neither is the incidence well documented; Niesen says that the literature cites rates that vary from 6% to 62%.

Despite the lack of supporting data, lymphedema is frequently cited as a contraindication to active exercise following medical treatment, says Dr. Susan Harris, a professor in UBC's School of Rehabilitation Sciences. Harris, who is also a breast-cancer survivor and a study participant, describes the current state of knowledge on lymphedema as "folklore."

Lymphedema can be unpredictable and irreversible, occurring anytime from 6 months to 10 years after treatment and causing pain and a debilitating loss of range of motion in the affected arm.

The first descriptive study at UBC began in September 1995. By June 1996, researchers had collected data from about 40 women (in a target group of 60 women) aged from 20 to 65 years who had completed treatment for stage 1 or 2 breast cancer at least 3 months earlier. The women are all self-referred to the study, mainly through breast-cancer support groups. A control group comprises women of similar age and activity levels who have not had breast cancer.

Subjects undergo a set of physical tests, including bilateral arm and chest strength testing (in which a piece of computerized, variable-resistance exercise-testing equipment is used), skin folds, range-of-motion tests of shoulders and cardiovascular evaluation while riding a stationary bicycle. Emotional status is also probed through three psychological questionnaires; their results are determined by a psychologist with experience in the cancer field.

The second study, which got under way in July, is investigating two groups of newly diagnosed women, 30 with stage 1 disease and 30 with stage 2 disease. The same baseline measurements as in the first project will be recorded before the women undergo surgery; Niesen says the participants could be seen "within days" of diagnosis.

Testing will be repeated regularly following the first radiation treatment, and again 2 weeks after the final radiotherapy session. Follow-up testing will continue every 2 months for a year to track cardiovascular and muscle-strength recovery patterns, as well as emotional health.

The third study, which is due to begin in January, will recruit another group of 40 women who have been treated for early-stage breast cancer -- including removal of axillary lymph nodes and radiation -- within the previous year. The primary goal will be to assess the impact of graduated exercise on shoulder range of motion, arm strength and the prevention of lymphedema. A secondary goal is to see if there are any differences in arm circumference, indicating swelling, between the "surgical" and "nonsurgical" arms.

The women will be randomly assigned to an exercise (treatment) or control (no treatment) group. Women in the treatment group will be instructed three times a week for 12 weeks in an exercise program designed to strengthen both arms; it will also emphasize cardiovascular exercise such as walking or cycling. At the end of the 3-month period, women in both groups will be retested to determine arm strength, arm circumference and shoulder range of motion.

The researchers hope to learn which levels of exercise are safe for women who have undergone lymph-node removal as part of their treatment. Niesen acknowledges that lymphedema is unpredictable, but hopes that a graduated exercise program may decrease the likelihood of swelling. She also thinks that graduated exercise throughout treatment will help patients tolerate the potentially gruelling effects better, allowing them to return more quickly to their former activities.