Recovery Fitness and Survivorship From Breast Cancer
by Dr. C.H. Weaver M.D. updated 10/2020
Breast cancer is the second leading cause of cancer death in women in the United States, with approximately 200,000 cases diagnosed each year. Depending on the extent of the cancer, some women may benefit from adjuvant therapy. Adjuvant therapy is a treatment that is added to increase the effectiveness of a primary therapy. Adjuvant therapy may include chemotherapy, radiation therapy, biologic therapy or hormonal therapy. These adjuvant treatments can be administered alone or in combination after surgery to increase the chances of curing the cancer or prolonging a remission.
Breast cancer surgery and adjuvant therapy is often associated with side effects such as fatigue, nausea, anxiety and depression. Following surgery complaints of stiffness, pulling, tightness, and a lack of flexibility are common. Often this occurs when the muscles and the skin are shortened because of the surgery, which can also leave scar tissue. Surgery can irritate the nerves. As a result some patients feel burning, tingling, or numbness. As a result, women often discontinue physical activity in an effort to cope with the side effects. However, this inactivity can actually sometimes exacerbate their condition, causing a decline in physical functioning and overall well being.
Researchers from Brigham and Women’s Hospital and Harvard University conducted a clinical study to evaluate the effects of exercise on survival in women diagnosed with breast cancer. This study included nearly 2,300 women who were participants in the Nurses’ Health Study. All women had been diagnosed with stages I, II or III breast cancer between 1984-86 and followed for almost 20 years.
Data indicated that the risk of death was decreased with physical activity, whether the amount of physical activity was modest or more intense, compared with being sedentary. The risk of death from breast cancer was decreased by 19% in women who had 3 to 8.9 met-hours per week of exercise; 54% in women who had 9 to 14.9 met-hours per week of exercise; 42% in women who had 15 to 23.9 met-hours per week of exercise; and 29% in women who had 24 or more met-hours per week of exercise. In terms of walking, this translates into a 19% reduced risk of death with just one hour of walking per week, and a 54% reduced risk of death with just 3 hours of walking per week. (1)
Researchers at the Ottawa Regional Cancer Center in Canada have also conducted a study to evaluate the effects of exercise on physical functioning and quality of life during adjuvant therapy. The study included 123 women with stages I and II breast cancer who were divided into three groups: usual care, self-directed exercise intervention, and supervised exercise intervention. Participants in the usual care group received general advice from their oncologist regarding the benefits of exercise. The self-directed exercise participants received a home exercise plan and were asked to exercise 5 times a week for 26 weeks. The supervised exercise group participated in a supervised exercise program 3 times a week for 26 weeks. The exercise consisted of moderate-level aerobic activity such as brisk walking.
Both the self-directed exercisers and the supervised exercisers experienced a significant improvement in physical functioning and aerobic capacity. These groups of women were able to participate in physical activity while undergoing adjuvant therapy, without any reported adverse effects from the activity. The researchers evaluated the data for all women and also evaluated the data based on whether participants were receiving chemotherapy. Of the 123 women, 83 were receiving chemotherapy. While both exercising groups experienced improved physical functioning and aerobic capacity, these gains were slightly lower in women receiving chemotherapy.
These studies suggest that physical activity following treatment for early stage breast cancer can reduce the risk of death and help diminish the negative side effects of breast cancer treatment, including reduced physical functioning, thus, improving quality of life for these patients. Women who have been diagnosed with early breast cancer should speak with their physician about the risks and benefits of different types of exercise and/or a specific exercise program to be implemented during and after treatment. (1.2,3)
Start an Exercise Program After Treatment for Breast Cancer
Exercise is good for our emotional health. It is one thing that you can control and do for yourself. It is empowering. Physical activity can decrease depression, fatigue, and anxiety. Participants in exercise programs reduce stress, increase confidence, and build positive health habits. The participants also gain endurance, increase their energy level, and decrease the fatigue that may be caused by treatments.
Exercise Progression: Many variables determine the exercises that are safe and effective for your particular situation. Every day brings new challenges and new accomplishments for the cancer patient. It is important to be able to modify your exercises to fit your needs at a given time.
Pain and fatigue levels can change from day to day and even from hour to hour. You may wake up feeling fine but may have increased fatigue as the day progresses. Track your energy levels throughout the day to determine the best time to schedule your exercise sessions. For example, if you have more energy in the afternoons, you should exercise in the afternoons.
Exercise when your energy levels are high. Common sense and listening to your body are of utmost importance. You should not feel like you have to follow a set protocol or a strict schedule. Your routine must be customized due to the numerous physical and psychological side effects you may be experiencing.
Both healing times and pain tolerance can differ greatly from one person to the next. Speed of recovery depends on your presurgery fitness level and the type of surgery and treatments. The progression and the timing of a cancer exercise program can be determined only after a thorough discussion between the patient and her healthcare provider. If you need someone to train you and guide you through the exercise, then you should hire a FitnessTrainer.
Relaxation Breathing: There is an emotional toll that cancer survivors face in addition to the physical one. A cancer diagnosis can cause depression, anger, anxiety, fear, and stress. Proper breathing techniques and stretching can improve the psychological recovery.
For example, research has shown that breathing can help reduce stress and anxiety. When feeling stressed, we usually take shallow breaths. During breathing exercises, we use our full lung capacity and breathe slowly and deeply. You should be aware of your breathing, as it has a calming effect.
Inhale for five seconds and fill the torso with air, then exhale from the lower abdomen for five seconds, pulling the navel in toward the spine. Imagine all of your tension and stress leaving your body with each exhalation.
You should begin relaxation breathing immediately after surgery, as it allows you to focus all of your energy on healing. Stretching will restore mobility in the chest and back, which allows for freer movement of the lungs and the diaphragm.
Aerobic Exercise: Aerobic exercise is essential for good health. This includes any movement that elevates your heart rate. As soon as you have medical clearance, you should start walking. Chemotherapy and radiation can cause fatigue. It may seem counterintuitive, but physical activity can help decrease fatigue and help you improve your ability to tolerate treatments. Walking can boost your energy.
Even if you are able to walk only one house distance at first, every day try to walk a little farther until you are able to walk for 30 to 45 minutes. If this is not possible because of health issues, aim for 15 minutes one to three times a day. Try to exercise when you feel the least tired. You may feel exhausted at various times during treatment and recovery, especially during chemotherapy and radiation. When you feel better, try to do more. Ultimately, the workout will help energize you and ease your aches and pains.
According to the results of a study published in the Journal of Clinical Oncology, participation in an eight-week program of supervised aerobic exercise significantly improved the quality of life of women who had been treated for breast cancer. To explore the effects of exercise among women who have completed breast cancer treatment, researchers in the U.K. conducted a study among 108 women who were one to three years beyond the end of breast cancer treatment. Prior to the study, none of the women engaged in regular physical activity.Study participants were assigned to one of the three groups:
- Supervised aerobic exercise therapy
- Exercise-placebo (body conditioning)
- Usual care
Women assigned to the aerobic exercise group participated in one-on-one sessions with an exercise specialist three times per week for eight weeks. The sessions lasted for 50 minutes and involved moderate-intensity exercise.Women assigned to the exercise-placebo group also attended 50-minute sessions with an exercise specialist, but the sessions involved light-intensity body conditioning and stretching rather than aerobic exercise.Women in the usual care group continued their lives as usual.(4)
- Compared to the women in the usual care group, women in the aerobic exercise group reported significantly better quality of life.
- Psychological health outcomes were modestly improved in women in the two intervention groups (aerobic exercise and exercise-placebo) compared to women in the usual care group.
The researchers conclude, “Exercise therapy had large, clinically meaningful, short-term beneficial effects on [quality of life] in women treated for breast cancer.
Stretching: Stretching exercises developed with your physical therapist or an exercise professional trained in cancer recovery exercise should be performed every day for a year or longer, depending on your particular situation. The older you are, the more important daily stretching is to maintain flexibility. Commit to stretching regularly so that you gradually improve your posture, range of motion, and flexibility.
First, warm up for five to 10 minutes by marching in place, or use a stationary bicycle while swinging your arms. Then perform the stretching exercises two to five times per day in the beginning of your recovery. Use only smooth, controlled, non-bouncy movements.
All movements should be done slowly and with great concentration. Try to reach the maximum pain-free range of motion possible for you. Stretch slowly and allow the tissue to lengthen. Hold the stretch until you feel a little tension—but not to the point of pain. The goals are to restore joint mobility and break down residual scar tissue. Always feel free to modify any stretch to your ability by going only a fraction of the distance.
At first you might suffer from fatigue and low endurance and might be able to exercise for only a short period of time. Every day you can lengthen the session. Patience and practice will pay off. As you get stronger, you can increase the length of the sessions.
Once you have achieved an acceptable range of motion, it is usually necessary to continue the stretching program so that you can maintain that range of motion. If you have had radiation, stretching is very important to help keep your body flexible. Radiation typically causes additional tightening. The impact of radiation on the affected area can last for a year or longer after treatment has ended.
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Important: If you notice swelling or tenderness, contact your healthcare provider.
Strength Training: Strength training improves balance and posture by increasing core strength. It can improve your quality of life by making activities easier and more enjoyable. It can also reduce the chance of injury and can empower you physically and mentally.
Another reason to strength train is because chemotherapy can cause weight gain and can change the muscle-to-fat ratio. Strength training improves the muscle-to-fat ratio. We need to gain muscle mass, which can decrease during treatment, and we need to strengthen bones. Having more muscle increases metabolism. A pound of muscle burns twice as many calories as does a pound of fat, so strength training is a great way to help get your weight to a healthy level and keep it there. While diet is often the most critical factor for weight loss (and is beyond the scope of this article), strength training is a major factor as well.
Many cancer treatments can increase the risk of osteoporosis. Strength training helps build strong bones. You need to learn which exercises are contraindicated for osteoporosis. For example, if you have or are at risk for osteoporosis, you should not do forward bends, abdominal crunches, or extreme twisting movements. Surgery can lead to weakness in the muscles of the chest, shoulders, abdomen, and back. Surgical patients need to rebuild strength in the affected areas and keep all the muscles in the body strong, as well as correct muscle imbalances.
According to a study published in the journal Cancer, twice-weekly weight training improved quality of life among breast cancer survivors. To evaluate the effects of weight training on quality of life and symptoms of depression, researchers conducted a study among 86 breast cancer survivors. The women had completed treatment between four and 36 months before the study began. Roughly half the study participants were randomly assigned to participate in a weight training program. The remaining study participants formed the comparison group. The weight training program lasted for six months and consisted of workouts two times per week. For the first three months, women worked out in small groups and were supervised by fitness professionals. For the next three months, women continued to train on their own. The weight training program involved nine exercises using weight machines and free weights. These exercises targeted the muscles of the chest, back, shoulders, arms, buttocks, hips, and thighs.The average age of study participants was roughly 53 years. A majority of women had been diagnosed with stage I or stage II breast cancer. Compared to women in the comparison group, women in the weight training group experienced significant improvements in quality of life.
- Women in the weight training group reported higher physical quality of life and higher psychosocial quality of life.
- Improvements in quality of life were linked with increased upper body strength and increased lean body mass.
- There was no difference between study groups in depressive symptoms.
The researchers conclude, “Twice-weekly weight training for recent breast cancer survivors may result in improved [quality of life], in part via changes in body composition and strength."
In a multiethnic study (42% African American and 31% Hispanic) breast cancer patients were assigned to participate in a yoga program or to receive usual care. (7) Overall, women who participated in the yoga program experienced a smaller decline in social well-being than women who received usual care. In addition, among the women who were not currently receiving chemotherapy, yoga improved overall quality of life and mood.
The exercise program evaluated gentle yet profound movement techniques combining the precision and the alignment of yoga, the core-strengthening methods of fitness, and the nonlinear, expansive nature of dance. The goal of the program is to build strength, gain flexibility, and restore balance. Here are three exercises from The Next Step: Restorative Exercises after Breast Cancer. (8) By retrieving range of motion in creative ways, we truly can reach a place called “the best shape of our lives.”
- Twist Sequence -*This exercise can be done on a chair or a ball.*Inhale with your arms over your head, palms facing each other. Lengthen your spine as you keep your shoulders “reaching” down your back. Exhale as you gently twist to the left, placing your right hand on the outside of your left knee and your left hand behind you on the ball. Allow the twist to initiate from the belly (not the shoulders) and keep your head in line with the sternum. Hold this posture for three breaths. Inhale as you release your left hand and place it on your head. Exhale as you reach your elbow to the ceiling, stretching your triceps, armpit, and side ribs. Hold this posture for three breaths if you can. Repeat the sequence on the other side.
- Camel Pose Variation - Sit on the front edge of a chair with your feet directly under your knees. Reach behind you and grab the sides of the chair back. If that is too much of a strain, slide your hands down and hold onto the seat of the chair anywhere that is comfortable. With your arms straight and your chin slightly tucked so that your neck stays long, lift your heart to the ceiling while your shoulder blades “reach” down your back.
- Cat-Cow Variation - This exercise can be done on a chair or a ball. Inhale as you open your arms out to the sides, lift your heart to the ceiling, and extend your pelvis back behind you, creating a gentle arch in your spine. Exhale as you reverse the movement by bringing your pelvis forward, pulling your belly in toward your spine, and bringing your hands in toward your heart. The initiation of these movements comes from the abdominals. The shoulders, neck, and chin are not leading the movement but responding to the cues of your core. Matching breath with movement, do this sequence five times.
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- Holmes M, et al. Physical activity and survival after breast cancer diagnosis. Proceedings from the 95th annual meeting of the American Association for Cancer Research. March 2004. Abstract #1462.
- Journal of Clinical Oncology, Vol. 19, No 3, pp. 657-665, 2001
- Mutrie N, Campbell AM, Whyte F et al. Benefit of supervised group exercise program for women being treated for early stage breast cancer: pragmatic randomized controlled trial. British Medical Journal [online publication]. February 16, 2007.
- Daley AJ, Crank H, Saxton JM, Mutrie N, Coleman R, Roalfe A. Randomized trial of exercise therapy in women treated for breast cancer. Journal of Clinical Oncology. 2007;25:1713-1721.
- Ohira T, Schmitz KH, Ahmed RL et al. Effects of Weight Training on Quality of Life in Recent Breast Cancer Survivors. The Weight Training for Breast Cancer Survivors (WTBS) Study. Cancer. Early Online Publication March 27, 2006.
- Courneya KS, Segal RJ, Mackey JR et al. Effects of aerobic and resistance exercise in breast cancer patients receiving adjuvant chemotherapy: a multicenter randomized controlled trial. Journal of Clinical Oncology [early online publication]. September 4, 2007.
- Moadel AB, Shah C, Wylie-Rosett J et al. Randomized controlled trial of yoga among a multiethnic sample of breast cancer patients: effects on quality of life. Journal of Clinical Oncology [early online publication]. September 4, 2007.
- Adapted from Exercises for Cancer Survivors (Friesen Press, 2013)