Your FAQs...Answered!

TON - April 2012, Vol 5, No 3 — April 30, 2012

Q: Is it safe for women at risk for breast cancer–related lymphedema to lift weights?

A: The short answer is yes, with caveats. Exercise for patients with breast cancer with, or at risk for, lymphedema is one set of recommendations for which there is actually evidence-based literature support. Many are not aware that most of the recommendations health professionals make regarding precautions to decrease the risk of lymphedema are based on knowledge of the pathophysiology and years of clinical expertise, but not on evidence. 

The fact that physical activity affects one’s energy supply, decreases fatigue and depression, maintains function, increases bone mass, and even lowers the risk of breast cancer has been accepted for awhile. However, previous to the late 1990s, it was felt that strenuous exercise needed to be avoided to prevent lymphedema. The possibility that upper extremity exercise could improve range of motion, prevent muscle atrophy, improve the pumping action of the muscle, and stimulate the immune system was largely ignored.

Then Donald McKenzie, MD, PhD, at the University of British Columbia, decided to test his theory that exercise was beneficial. In February 1996, he formed a dragon boat team of breast cancer survivors. This diagnosis of breast cancer was the only criterion to join the team. McKenzie chose dragon boat rowing because it was a strenuous, repetitive upper body exercise that he felt sent a visible message to people with breast cancer. Being a non–weight-bearing activity, it was associated with lower risk of physical injury than weight-bearing activities. Reasonable amounts of muscle mass are recruited.

Frequency, duration, type of exercise, as well as intensity, was prescribed in a progressive manner. Prescriptions started with strengthening and stretching exercises and included suggestions for aerobic fitness. The 24 paddlers who signed up ranged in age from 31 to 62 years. They chose the team name “Abreast in a Boat.” No new cases of lymphedema arose in these women. Several women reported an increase in shoulder range of motion, and one even reported resolution of a reflex sympathetic dystrophy. Anecdotally, all paddlers had an improvement in both physical and mental health.

So what is lymphedema and why might exercise, including weight lifting, be beneficial for patients with breast cancer? Lymphedema of the skin and subcutaneous tissues is the most common clinical manifestation of the lymphatic fluid (load) exceeding the transport capacity for lymphatic fluid, ie, the body is unable to drain lymph fluid from the tissues. Lymph fluid is composed mainly of water and protein but also contains fatty acids, salts, white blood cells, microorganisms, and foreign debris.

In breast cancer patients, a functional or anatomic abnormality due to surgery and/or radiation causes a reduction in the transport capacity of the lymphatic system. Lymphatic insufficiency or failure occurs, and interstitial edema results. The edema worsens because of osmosis: trying for a state of balance, the protein in the lymphedematous fluid draws more water into the lymphatic system to dilute the lymph fluid. Additionally, the white blood cells are unable to work properly in lymphedematous fluid, so the risk for infection increases. Lymphedema is a chronic condition. If not treated very early, it can cause progressive swelling, fibrosis of soft tissues, infections, pain, and/or paresthesias.2

Table 1
Predictors of Lymphedema After Breast Cancer Surgery.

In the past it was believed that exercise increased the flow of blood to tissues and thus increased the workload of the already overloaded system. Women were told not to lift children, heavy bags, or other items with the affected arm. However, this claim has not been supported in the evidence-based literature. In fact, more current literature speaks of the benefits and safety of exercise. Exercise increases muscle mass, which increases the capabilities of the muscular pump responsible for the movement of the lymph fluid. Additionally, it increases flexibility and strength and combats obesity (a risk factor for lymphedema).3 Swenson and colleagues found that strength training was a predictor of less lymphedema.4 Avoidance of exercise may recondition the arm and increase the chance of overuse, resulting in injury and potentially lymphedema. (See Table 1 for other factors that have been identified to increase the risk of lymphedema after breast cancer treatment.) 

Courneya and colleagues studied the effects of both aerobic and resistance exercise in breast cancer patients initiating chemotherapy. This was a multicenter randomized controlled trial involving 243 patients. Patients were assigned to usual care, supervised aerobic exercise, or supervised resistance exercise for the duration of their chemotherapy. The primary end point was quality of life; occurrence of lymphedema was one of the secondary end points. The authors’ conclusions were that neither type of exercise significantly improved cancer-specific quality of life, but they significantly improved self-esteem, physical fitness, body composition, and chemotherapy completion rate without causing lymphedema.

Two more recent randomized controlled trials focused specifically on weight lifting in women at risk for or with breast cancer–associated lymphedema. 

In a pilot study, Schmitz and colleagues, at the University of Pennsylvania, recruited 141 women with a history of breast cancer and current lymphedema. Inclusion criteria included a unilateral nonmetastatic breast cancer, diagnosis 1 to 15 years prior, body mass index (BMI) ≤50, not actively trying to lose weight, no evidence of cancer at the present, no medical conditions that limit exercise, and no history of weight lifting during the previous year. Women were assigned by computer to 1 of 2 groups. The computer program balanced the groups by age (<54 vs ≥54); difference in volume between affected and unaffected limbs (<10% vs 10%-20% vs >20%); number of nodes removed (<6 vs ≥6); BMI (<30 vs ≥30); months since diagnosis (<60 vs ≥60); and whether they had received radiation treatment.6

Based on the hypothesis that a program of controlled weight lifting exercises may increase the work capacity of affected limbs and protect them from injury sustained during common activities, participants were assigned to either a control group (no exercise) or a supervised progressive weight lifting group. The latter group received a 1-year membership at a community fitness center. For the first 13 weeks, women received two 90-minute instructional sessions a week. They continued unsupervised exercise twice a week for another 39 weeks. There was no upper limit placed on the resistance level to which the women could progress.

After a year, there was no significant difference between the groups in the number of women who had an increase in arm swelling of ≥5% as assessed by certified lymphedema therapists. In fact, weight lifting reduced the number and severity of arm and hand symptoms and reduced the number of lymphedema exacerbations. Additionally, muscle strength was increased. The program developed in this study is available to breast cancer survivors at YMCAs across the country through the LIVESTRONG at the YMCA program.6

Schmitz and colleagues then recruited a group of women who did not have lymphedema but were at risk. Most breast cancer survivors do not have lymphedema; nevertheless, they alter the use of their upper limbs out of fear of developing it. Therefore, the Physical Activity and Lymphedema study was conducted to assess if exercise is safe for this group. The goal was to evaluate the incidence of lymphedema that could be attributed to weight lifting.

Inclusion criteria in this study included nonmetastatic breast cancer diagnosis 1 to 5 years before; BMI of ≤50; no evidence of cancer; no medical conditions that would limit participation; no plans for surgery or to be away for 1 month during the study; stable weight, and not trying to lose weight; at least 2 lymph nodes removed; and no prior or current lymphedema diagnosis. Of the 3200 women recruited, 154 were found to meet the criteria and were randomized to 1 of 2 groups, again using a computer program to balance potential baseline confounders. Women assigned to the exercise group received a fitness center membership and supervised instruction for progressive weight resistance increments for 13 weeks, similar to the intervention in Schmitz’s first study, and then exercised without supervision for the next 39 weeks. Women in the control group were asked not to change their baseline activity level but were offered a 1-year fitness center membership as well as 13 weeks of instruction after the study was completed.7

Women in the weight lifting group gained strength, had a lower percentage of body fat, and had <5% increases in volume between their 2 arms. The control group had a 17% (13 of 75 patients) occurrence rate of those having ≥5% volume increase, while the weight lifting group only had an 11% (8 of 72 patients) occurrence rate. There were 3 cases of clinician-defined lymphedema in the control group and only 1 in the weight lifting group. A secondary analysis looked at women who had ≥5 nodes removed. In the control group, 22% experienced an increase in interlimb volume of ≥5%, compared with only 7% in the weight lifting group. This was a reduction of 70%.7

The authors concluded that there was no increase in the risk of developing lymphedema with a program composed of slowly progressive weight lifting compared with no exercise and that there was the chance of a decrease in the onset of swelling in women who were deemed to be at higher risk due to the removal of ≥5 nodes. They recommended that all breast cancer survivors start participating in weight lifting in order to experience the health benefits it provides.

Based on these results, recommendations for preventing and treating lymphedema in breast cancer survivors have been updated. The National Lymphedema Network (NLN) has issued a position statement on exercise. NLN states that exercise is an important component to maintaining health and that the majority of patients at risk for lymphedema can safely perform aerobic and resistance exercise if the exercises are initiated at a low intensity and increased gradually. There is no clear evidence that wearing a compression garment is helpful for those at risk. For those with lymphedema, aerobic and resistive exercise are still considered safe as long as compression garments are worn on the affected body part(s); the affected body part(s) are not exercised to fatigue; and appropriate modifications are utilized to prevent trauma and overuse injury.8

The American Cancer Society states “It’s important to use your affected arm for normal everyday activities to help you to heal properly and regain strength. This includes doing things like brushing your hair and bathing. Using your muscles also helps drain lymph fluid from the limbs. If you’ve had surgery or radiation treatment, ask your doctor or nurse when you can start to exercise and what type of exercises you can do. But keep in mind that overuse, which can result in injury, has been linked with the start of lymphedema in some women. It’s a good idea to follow these tips: 

  • Use your affected arm as normally as you can. Once you are fully healed, about 4 to 6 weeks after surgery or radiation treatment, you can begin to go back to the activities you did before your surgery
  • Exercise regularly but try not to overtire your shoulder and arm. Before doing any strenuous exercise, such as lifting weights or playing tennis, talk with your doctor, nurse, or physical therapist. They can help you set goals and limits so that you can work at the level of activity that is right for you. Ask your doctor or physical therapist if you should be fitted for a sleeve to wear during strenuous activities 
  • If your arm starts to ache, lie down and raise it above the level of your heart 
  • Avoid vigorous, repeated activities, heavy lifting, or pulling 
  • Use your unaffected arm or both arms as much as possible to carry heavy packages, groceries, handbags, or children”9
Table 2
Lymphedema Resources.

Lymphedema remains of great concern to breast cancer survivors because it has such a significant impact on their quality of life. It is important for healthcare professionals to know what factors actually influence the development of lymphedema. Many of the risk factors are not modifiable, but the addition of exercise, including a prescribed, progressive program of weight resistance, is one way to modify risk in a positive manner. Patients need education. A retrospective study of breast cancer patients revealed that those who developed lymphedema consistently stated that they received little or no education about this condition.

Pretreatment and posttreatment education need to take place and be reinforced throughout the continuum of survivorship.Remember, survivors should be medically cleared before starting an exercise program, and exercise needs to be started slowly and increased gradually. Exercise should be stopped for signs of injury such as pain or increased swelling. Refer to Table 2 for information resources available for both healthcare providers and patients.

References

  1. McKenzie DC. Abreast in a Boat—a race against breast cancer. CMAJ. 1998;159:376-378.
  2. Lawenda BD, Mondry TE, Johnstone PA.Lymphedema: a primer on the identification and management of a chronic condition in oncologic treatment. CA Cancer J Clin. 2009;59:8-24.
  3. Poage E, Singer M, Armer J, et al. Demystifying lymphedema: development of the lymphedema put- ting evidence into practice card. Clin J Oncol Nurs. 2008;12:951-964.
  4. Swenson KK, Nissen MJ, Leach JW, et al. Case-control study to evaluate predictors of lymphedema after breast cancer surgery. Oncol Nurs Forum. 2009;36:185-193.
  5. 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. J Clin Oncol. 2007;25:4396-4404.
  6. Schmitz KH, Ahmed RL, Troxel A, et al. Weight lifting in women with breast-cancer-related lymphedema. N Engl J Med. 2009;361:664-673.
  7. Schmitz KH, Ahmed RL, Troxel AB, et al.Weight lifting for women at risk for breast cancer–related lymphedema. JAMA. 2010;304:2699-2705.
  8. NLN Medical Advisory Committee. Position Statement of the National Lymphedema Network. Topic: exercise. www.lymphnet.org/pdfDocs/nlnexercise.pdf. Accessed October, 12, 2011.
  9. American Cancer Society. Lymphedema: what every woman with breast cancer should know. www.cancer.org/Treatment/TreatmentsandSideEffects/PhysicalSideEffects/Lymphedema/WhatEveryWomanwithBreastCancerShouldKnow/lymphedema-with-breast-cancer-to-prevent-lymphedema. Updated October 25, 2010. Accessed October 12, 2011.

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