September 2011 Ask the Expert: Fitness and Exercise
During the month of September, Living Beyond Breast Cancer expert Deborah Julie Franklin, MD, PhD, answered your questions about how to get and stay fit and how to exercise smartly and safely after breast cancer.
Dr. Franklin: You are right to identify doing too much as a potential problem for a committed athlete undergoing cancer treatment. You belong to a group of people who are used to making progress by pushing themselves. Even in the best of health, this is where we see overuse and related injuries.
Your body is already signed up for a decathlon as it tries to reverse the effects of chemotherapy, surgery and possibly radiation. A general recommendation for athletes is to reduce the duration and intensity of their program by at least 50 percent. So if you were running a 7-minute mile for 5 miles a day, your goal would be a 14-minute mile (brisk walk) for 15 minutes a day—basically a 1-mile walk. That is the goal, so there may be some days at what is called the nadir (lowest point) of a treatment cycle or if you are actively sick with fever when this will be too much.
The same 50 percent rule applies to resistance training. If you are truly completing the 50 percent workout effortlessly for at least 2 weeks you can consider increasing very gradually, but discuss this with your treatment team, particularly if you are in a clinical trial. Even moderately vigorous activity can your temporarily raise your white cell count, for example, making critical laboratory results difficult to interpret.
During the period after surgery, your surgical team will provide you with exercise guidelines for your upper extremities so that the incision can heal properly. While it is possible to return to your previous level of performance, doing it safely and wisely is a long-term commitment.
During the period where you are significantly reducing your program, you may want to identify the many things exercise does for you and means to you so that you can find supplementary ways of meeting these needs. For example, someone who bicycles, runs or rows to relieve stress may explore a mindfulness meditation class during treatment instead of relying on a 2-hour workout. Weight control concerns during a period of decreased activity can be reviewed with a nutritionist. People who play team sports may miss the social aspect as well as the exercise itself. While joining a cancer support group is not for everyone, it can provide the same camaraderie, particularly if other members are interested in finding ways to maintain fitness together.
Many cancer centers have adaptive exercise programs or can direct you to resources in your area. The Pink Ribbon Program trains instructors nationally to help women recover from breast cancer through exercise. In addition, Anna Schwartz has a chapter in her book, “Cancer Fitness: Exercise Programs for Patients and Survivors,” specifically written for athletes.
Dr. Franklin: Congratulations on completing treatment and returning to your previous passions.
In general, people who have completed treatment without documented enduring side effects (e.g. enlarged heart from certain types of chemotherapy; numbness in their feet) are encouraged to gradually ramp up towards their previous level of performance using indicators such as greater than usual fatigue, muscle soreness, etc. to prevent them from pushing too fast. It is hard to answer your question more specifically as it is not clear which laboratory tests your doctor was referring to when they said your blood work isn’t 100 percent back to pre-chemotherapy levels. Your white blood cell counts? Hemoglobin? Platelets? Kidney function? Protein stores? It’s most likely that your red and white blood cells (and therefore your hemoglobin level) haven’t fully recovered.
While there is no known damage that results from vigorous exercise with low normal cell counts, you may fatigue more easily, take longer to reach goals or even become more easily short of breath if your hemoglobin level is low. You should take this into account as your pace yourself and evaluate your goals and progress. I would also ask your doctor which test results they were referring to and if they have any concerns as your resume more intense training.
Dr. Franklin: Successful nutritional advice is based as much on a person’s previous food habits, tastes, physiology, preexisting allergies or health conditions as on the specifics of their cancer and its treatment.
It is generally easier to maintain energy throughout the day with 4-6 smaller meals than with fewer larger meals. Assuming normal or greater activity level, your daily calorie requirement can be estimated as = 25 x your weight in kilograms (2.2lbs/kg). Moderate or strenuous exercisers will have to adjust accordingly.
Staying well hydrated is also essential to achieving consistent performance, but pay attention to the calories, electrolytes and nutrients in what you drink.
Protein intake is vital for not only promoting healing after surgery but also for rebuilding muscle mass during training. There has been some controversy over the positive and possibly negative effects of soy products on estrogen receptors – this is important because many people, particularly vegetarians, turn to soy as a source of protein.
Dr. Franklin: You will probably need all three. Losing over 50 pounds and keeping it off is a year-long project. Although as much as 2-2.5 pounds a week can be safely lost by healthy adults, asking yourself to do that unfailingly for 6 months is a lot. Spreading it out over a year will allow you to succeed even if you slow down over a holiday weekend or a vacation.
Weight loss is primarily the result of using up more energy than you are taking in through the calories in food. Fluid shifts and other factors play a role in your day-to-day weight, but over time, every time you “burn” 2,500 more calories than you eat, you lose one pound. Therefore, how fast you are walking, using the elliptical machine or what your boot camp leader asks of you will determine how much weight you lose and how quickly.
A 200 pound/90 kilogram woman will burn about 300 extra calories if she walks 3 miles in one hour; more as she is able to tolerate a faster pace. Many elliptical machines and treadmills will estimate calorie expenditure based on weight so you can compare yourself at different speeds. Being able to alternate equivalently effective types of exercise will prevent you from getting bored and losing interest in the project. Outdoor walkers may need an indoor option during heavy rain or snow.
While many people tolerate light to moderate exercise daily, more intense training should be part of a well-balanced program that includes time for your body to recuperate. Once again I would like to recommend Anna L. Schwartz’s book, “Cancer Fitness,” for further guidance.
Dr. Franklin: Even though lymphedema after breast cancer is a lifelong condition, it can usually be controlled with decompressive therapy coupled with long-term use of a compression garment. The package is what is requested when Comprehensive Decongestive Therapy (CDT) is prescribed. Because exercise with compression helps stimulate lymphatic drainage, some amount of supervised upper body exercise is usually part of the initial CDT/lymphedema therapy. Surgical history including type of reconstruction, radiation treatment, arthritis or other medical conditions may need to be taken into account as you increase your upper body activity level.
Published studies demonstrate that women with well-controlled lymphedema can return to a range of activities as long as they are compliant with their maintenance program, particularly the use of appropriate compression during and after exercise and prompt medical evaluation for any changes in circumference that do occur.
There are specific yoga poses that should probably be avoided as you return to your practice (salabhasana or locust pose, for example, where you lie face down on your internally rotated arms), but with careful coaching and great patience you might even be able to return to these as well. When properly done by a person who has worked up to them, yoga poses are designed to enhance not constrict circulation including lymphatic drainage.
Safe return to yoga or Pilates should be supervised by a teacher or therapist who understands both lymphedema and these exercise forms. Breastcanceryoga.com and pinkribbonprogram.com can help you find people who meet these criteria as well as other resources in case there is no one in your area.
Any symptoms such as new or increased pain or worsening edema in a limb that has been diagnosed as having lymphedema should be evaluated by a doctor. This can be your primary care doctor, oncologist, surgeon, radiation oncologist or cancer rehabilitation specialist (PM&R). Relatively minor conditions such as tendinitis or muscle strains can lead to lymphedema exacerbations if not treated appropriately. It may also be necessary to rule out an unrelated cause such as a blood clot.
Dr. Franklin: There are many reasons why you may experience shoulder pain when your arms are extended during standing poses or other yoga poses. This may also have been true if you were doing yoga after any number of other illnesses.
Your specific breast cancer treatment including type of surgery, reconstructive procedures, radiation and chemotherapy can affect shoulder function, as can a host of other conditions including early arthritis or overuse syndromes, to name a few. Pain in a pose means that you pushing too hard—lower your arms a little to where they are more comfortable or hold the pose for less time.
Discuss the problem with your yoga teacher if you take classes. Pain that persists after finishing your yoga practice and that persists throughout the day or evening should be discussed with your primary doctor, who may want to refer you to a physical medicine and rehabilitation (PM&R) specialist, sports medicine specialist or rheumatologist.
Yoga is an excellent form of exercise for people seeking to achieve whole body strength and flexibility as well as many of the psychological benefits that come from regular exercise of this type. People with significant bodily change after treatment for breast cancer, such as TRAM (transverse rectus abdominis myocutaneous) reconstructions, may need to work with a specialist to design a safe program.
While yoga can be very physically demanding and certain types help develop more cardiovascular endurance than others, persons seeking aerobic training or weight loss goals may need to supplement their yoga practice with additional activities such as running, cycling or rowing.
Dr. Franklin: October 3 is not that far away. The good news is that if you have been tolerating bike riding and running three times a week without unfamiliar shortness of breath or exhaustion, you are probably not in big trouble.
That being said, a number of factors could be accounting for your recent ejection fraction (EF) results. Assuming this is a change from your pre-treatment baseline, then the fact that you are on “break” doesn’t mean that the Herceptin isn’t still at work and that your heart isn’t experiencing increased demand as a result of whatever impact the Herceptin or other factors may have had.
Walking until you meet with the cardio-oncologist is prudent. They may want to perform additional tests to confirm that the reduction in your EF is in fact due to Herceptin and not other causes, and they should be able to guide you in establishing safe exercise guidelines. Your job is to make sure they understand your previous fitness regimen and goals and take the time to answer your questions or refer you to someone who can. If it turns out that you have experienced a significant change in cardiac function, you may want to ask about being referred to an outpatient cardiac rehabilitation program.
Dr. Franklin: You are doing plenty. You have just been through an incredibly demanding physical experience. Attending to basic needs plus or minus returning to work may be exercise enough for a few weeks.
After basic self care, your priorities should be recovering arm strength, function and range under the supervision of your surgeon or a physical/occupational therapist that they have referred you to. Let your surgeon, medical or radiation oncologist or their staff know if you do not have the time, energy or money to go to an outpatient therapy center. They should be able to provide you with a home exercise plan to prevent contractures (stiffness) or other complications from developing while you get your energy back.
Light exercise such as the half mile walk you are doing is often helpful during the immediate recovery period for those who can tolerate it. It is wonderful that you have been able to return to this so quickly. If you do not find your endurance improving over the next months, bring this to your oncologist’s attention. You may be limited by anemia or other medical conditions that can be addressed. The American Academy of Physical Medicine and Rehabilitation can also help you locate a rehabilitation medicine physician to guide you further.
An increasing number of physical therapists and exercise trainers are beginning to specialize in helping cancer patients after treatment, but prior consultation with a physician is advisable for patients with complex treatment courses. All licensed physical and occupational therapists should be able to provide safe programs for cancer patients. The American College of Sports Medicine currently offers a certification program for exercise trainers interested in working with cancer patients.
Dr. Franklin: When thinking seriously about body weight, the pounds we carry around need to be put into the context of BMI (Body Mass Index). Your BMI is your weight in pounds adjusted for height: [weight (lbs) x 703/height (in)]. Your BMI is one of the main ways that doctors, nutritionists, insurance companies and others determine if you require interventions for obesity.
A thin, 5’7” woman who weighed 130 lbs (BMI 20.4) before treatment and who gained 40lbs (BMI 26.6) might feel uncomfortable, need to buy new clothes and be very motivated to pursue weight loss but probably would not be a candidate for bariatric surgery under current guidelines. On the other hand, a woman whose BMI was closer to 30 at the outset becomes increasingly vulnerable to the health complications associated with the diagnosis of obesity or morbid obesity (BMI >30 and >50 respectively).
There have been some small studies looking at the outcome of bariatric surgery in women who had already been treated for breast cancer. The most consistent finding has been that significant weight loss, whether through surgery or diet and exercise, can alter the appearance of certain types of breast reconstructions, so make sure to discuss your reconstruction with any doctor assessing you for weight loss surgery whether you have implants or a flap procedure. However, prior to pursuing any evaluation, make sure your oncologist is aware of your plans.
Significant weight loss may not be appropriate for all stages of breast cancer treatment or early survivorship. Even further out, you may require a more tailored plan if you are on any type of maintenance or preventive therapy, particularly one that influences calcium, protein or glucose metabolism.
Dr. Franklin: Congratulations on allowing your diagnosis to propel you towards a more active lifestyle. A newfound appreciation for health and wellness is not uncommon in women who have been treated for breast cancer but can be difficult to maintain without additional support.
An elliptical machine is an excellent way to safely pursue weight loss for several reasons. First of all, it is designed to increase energy and calorie use while protecting your arms, legs and back from much of the wear and tear they would experience if you were, for instance, just starting to run on pavement. This can be particularly important for heavier persons as their joints already carry a greater load.
Many elliptical machines also come with programming that lets you track your progress by recording your pace, duration of exercise and, in some cases, a rough estimate of how many calories you have used. Three days a week is a solid start, but you will notice greater gains if you are able to fit in four or five sessions a week, particularly if they are between 20 and 30 minutes.
As you start exercising more, you may want to learn about designing a program that includes days of shorter, more intense training that alternate with less demanding but longer sessions so that you increase strength and endurance with less risk of overuse injuries. Once again, Anna Schwartz’ book ”Cancer Fitness” is an excellent resource.
You mention both having had a mastectomy and being chesty. Some women in that predicament work with their breast surgeon to incorporate breast reduction surgery on the healthy breast with the initial mastectomy or subsequent reconstruction. Even if you don’t plan on this right now, you may want to raise the question with your breast surgeon during any follow up appointments you may have.
Dr. Franklin: I am assuming that the right shoulder pain is on the same side as your mastectomy, but actually it doesn’t matter. Persistent shoulder pain that limits movement and interrupts sleep should be evaluated by either your primary care doctor or an appropriate specialist (see below).
That said, shoulder pain on the operative side is not uncommon in women diagnosed with breast cancer regardless of whether they had mastectomies or breast conserving surgery and radiation. It is most frequently a condition called adhesive capsulitis or “frozen shoulder,” but you need to be assessed for other conditions that occur less commonly.
Adhesive capsulitis can occur spontaneously when you instinctively limit your arm movement during the post surgical period. As the joint becomes stiffer and more painful, you may move it even less, adding to the cycle of immobility and stiffness.
Fortunately this condition can be effectively addressed by a conservative regimen of outpatient therapy with an occupational therapist (OT) or physical therapist (PT) and medical management using some oral medications and, if indicated, a corticosteroid injection. However, a physician should first confirm that your pain and limitations are in fact due to adhesive capsulitis and not a complication of your cancer or its treatment or the result of an unrelated musculoskeletal injury or condition.
If your primary care physician is not comfortable making this diagnosis independently, particularly in light of your recent history, they may ask that you consult your original surgeon or a physician specializing in musculoskeletal conditions such as a physiatrist (physical medicine and rehabilitation specialist), orthopedic surgeon or rheumatologist. You can find a Physical Medicine and Rehabilitation (PM&R) specialist in your area by using the website of the American Academy of Physical Medicine and Rehabilitation.
Dr. Franklin: Weight gain, particularly during the first year after treatment for breast cancer, occurs for a number of reasons. It is actually more common among women who were at a healthy weight prior to diagnosis than among women who were already overweight.
While some studies have shown an association between treatment with tamoxifen and weight gain, others have not. Regardless of the cause or causes contributing to weight gain after breast cancer treatment, several studies have shown that a multidisciplinary approach integrating psychosocial support, exercise and nutritional counseling is the most effective intervention.
Psychological support can be provided through one-to-one counseling but is more frequently obtained through a moderated group. Many cancer centers offer ongoing meetings for women diagnosed with breast cancer. Some use the Look Good Feel Better format introduced by the American Cancer Society and the Personal Care Products Council, while others have developed their own structure.
Walking groups often grow out of these meetings and are an excellent way to increase activity for sedentary persons. The walking pace, however, has to be quite fast and sustained in order to achieve significant weight loss.
You describe yourself as previously fit. If there were types of exercise that you enjoyed prior to your diagnosis it is often good to return to these, although if they involved significant arm strength you may want to discuss it with your surgeon and/or oncologist first. I’ve had two patients recently who took trapeze classes, so I have become less casual about assuming that all fitness programs can be resumed without additional input.
You may want to start your exercise routine with someone who has been certified by the American College of Sports Medicine (ACSM) as a Cancer Exercise Trainer (CERT). Keeping a food log and reviewing it with a nutritionist will probably be helpful as well. One associated with a cancer center will, of course, have the greatest experience and understanding of what you are going through and how to help.
Dr. Franklin: Qigong has been shown to be effective for improving quality of life, fatigue, depression and psychological distress in women with breast cancer, although I am not aware of any studies specifically analyzing the impact for women living with stage IV disease. There is no reproducible literature suggesting that it reduces tumor size or disease progression in local or metastatic disease.
Basic qigong with an emphasis on breathing and meditation is safe in almost any setting. However, some of the more dynamic practices including calisthenic-type exercises, external agents, herbs or dietary modification should be pursued with greater caution during active cancer treatment or when disease progression is suspected.
Dr. Franklin: While walking can a good form of exercise, it needs to be done at a certain pace (usually 13 minutes per mile or faster) in order to experience meaningful benefits. Reaching 70-80 percent of your calculated maximum heart rate (MHR) is a good way to assess if your pace is adequate.
For research purposes MHR is a heart rate adjusted for age, weight and other factors, but in daily life a simpler formula adjusting for age is used. Numerous calculators are available online and in exercise books, but a personal trainer at a gym can also help you if you are having difficulty. Exercise recommendations are usually based on reaching 70-80 percent of this calculated MHR, but this may need to be reviewed by a doctor if you experienced considerable loss of strength or energy during your cancer treatment.
Once a safe target heart rate has been identified for you, your goal will be to exercise at that rate for at least 20 minutes with a warm up and cool down session at either end. Doing this 4-5 times a week is the best way to improve fitness, although 2-3 times a week is certainly preferable to not doing it at all. The rate at which your strength and endurance improves will just be slower.
Sustained walking can be challenging on city streets with traffic lights, vendors, dog walkers, etc. Faster walking can also create musculoskeletal strain on your upper as well as lower body if not done with some attention to posture and footwear. Arm placement and arm swing may be particularly important for women after mastectomy, axillary dissection, certain types of reconstructions or for those with lymphedema.
Printed and online instructions such as the aerobic walking guidelines at http://www.oohoi.com/ may be sufficient. However, if you experience any symptoms such as arm pain, shoulder pain, shortness of breath that does not resolve with rest, back or leg pain, you may want to review your program with a cancer rehabilitation specialist (physiatrist, physical therapist, certified cancer exercise trainer) before continuing.