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Exercise after Breast Cancer: Promoting a

Healthy, Happy Recovery

Joy Kiviat, PhD, MSN, RNOncology Certified Nurse

University of Arizona College of NursingACSM certified Cancer Exercise Trainer

and Group Exercise Instructor

Educational ObjectivesParticipants 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

resources

Cancer & ExerciseResearch indicates that cancer

patients who exercise: report less fatigue require fewer blood transfusions are hospitalized less frequentlyare less likely to fallhave 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, AND….

• 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)

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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)

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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 messengersResult: 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)

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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)

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Increased Flexibility

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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?

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Addressing Concerns• Readiness test• Motivating• Preparing• Persisting• Evaluating

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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

consciousness? • 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

activity? • *Adapted from Physical Activity Readiness Questionnaire (PAR-Q)

developed by the British Columbia Ministry of Health & Multidisciplinary• Board on Exercise

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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 guidelines

If you answered no to all:• you can be confident that you can exercise safely • It is still important to start slow, increase gradually

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• 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

What about Lymphedema?

Group classes (YMCA, community centers, fitness clubs)

Personal trainer (some make house calls)Walking (suggest finding walking buddy or dog for

companionship and motivationSwimming (good for persons with joint or bone pain)Exercise videos and FitTV channelBetter than Ever program at UACancer Center

Exercise Options

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

19Source: 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. doi:10.1188/12/12.ONF.269-274

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

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 361:664-73.

References, cont.