Did you know that every three minutes another woman is diagnosed with breast cancer? If you have clients with breast cancer, you can have a great role in their recovery, as the treatment that these women and men (men can get breast cancer too) must undergo can have both physical and psychological ramifications. Most breast cancer survivors will live many years after receiving medical care. How can you as a personal trainer optimize their recovery and improve their lives? Before implementing a fitness program, it is important to understand the disease and the treatments provided. The purpose of this article is to:
- Educate fitness professionals about breast cancer and the medical interventions indicated.
- Provide strategies to design a basic exercise program that is safe and effective yet meets individual needs.
Breast cancer is abnormal cell growth or a tumor that invades and destroys normal tissue. It is categorized into stages: Stage 1 (least serious) to Stage 4 (most life threatening). Staging is a method of grouping patients by the extent of the disease to predict prognosis, determine the type of treatment and compare different treatment approaches. Stage 1 has a better prognosis because the tumor is smaller and no lymph nodes are involved, while Stage 4 is metastatic breast cancer, which is cancer that has spread to the bones liver, lung or brain. The most common route of spread is through the auxiliary lymph nodes in the armpit. From this staging and other tests, treatment can be prescribed. Other factors that determine treatment include menopausal status and lifestyle requirements.
There are two types of treatment: local and systemic. Local treatment pertains to the actual site of the tumor and includes surgery and radiation. All women receive surgery for breast cancer. The surgical treatment depends on the location and size of the lesion, analysis of menopausal status, breast size, patient’s age and how the client feels about breast preservation. The major types of surgery are as follows: lumpectomy (breast conservation), mastectomy or modified radical mastectomy. In the case of lumpectomies, the tumor is excised or removed with a partial auxiliary lymph node dissection (removal). This procedure is sometimes followed by radiation. Mastectomies involve removal of the entire breast including the nipple. In most cases, no lymph nodes are excised. However, when a modified radical mastectomy is performed, the entire breast is removed as well as lymph nodes. The chest muscles are spared. Cosmetic deformity, psychosocial concerns, chest wall tightness, loss of a body part and an altered body image are all side effects after mastectomies. However, if a woman so desires, mastectomies can be followed up by reconstructive surgery. Breast reconstruction can make a big difference physically and emotionally for mastectomy clients. This is another option for women after a mastectomy who prefer the creation of a breast rather than using a prosthesis. There are several ways to reconstruct the breast; each have their own advantages and disadvantages. In one method, an inflatable prosthesis is placed under the muscles of the chest and gradually inflated with saline for the implant procedure. This requires about two to three months bi-weekly before the breast reaches the size of the opposite breast.
Possible problems include capsular contracture and implant rupture. Another procedure uses the latissimus dorsi, which is rotated around to the chest wall along with the use of an implant. If the latissimus dorsi is removed, it can impair muscle power for some sports such as tennis or swimming. The Transverse Rectus Abdominus Myocutaneous (TRAM) flap is the most complex procedure. The rectus abdominus, blood vessels, skin and fat from the lower abdomen are transferred onto the chest wall and shaped into a breast. This requires a lengthy recuperation period but results in a more natural looking and feeling breast. A tummy tuck makes this procedure attractive, but clients are at risk for hernias secondary to weakened abdominal musculature. Reconstruction can be performed right after the mastectomy or after chemotherapy and radiation, depending on the medical intervention recommended. Reconstruction is delayed if radiation therapy or chemotherapy has to be provided or if the tumor is large. Radiation is a local treatment that uses high energy rays to damage cancer cells and prevent them from growing and multiplying. It is provided five days a week for five weeks. It usually follows lumpectomies three to four weeks after surgery or after chemotherapy is administered. Side effects include scar fibrosis, skin irritation, burns, breast swelling and tenderness and fatigue.
Systemic treatments affect the entire body and include chemotherapy and hormonal treatments. Chemotherapy is the use of cytotoxic (cell killing) drugs. Both cancerous and non-cancerous cells are affected and may be damaged in the process. All body systems are involved including the gastrointestinal, musculoskeletal, cardiovascular and neurological systems. Everyone responds differently. However, rapidly dividing cells in the hair and the intestine are the most affected, resulting in hair loss, vomiting and nausea. It is administered once every three to four weeks for approximately four to six months. Other side effects include diarrhea, fatigue, premature menopause, weight gain, cardio toxicity, anemia and peripheral neuropathies. A risk of infection due to a drop in white blood cells can be experienced, and a decline in red blood cells leads to fatigue. If a woman needs both chemotherapy and radiation, chemotherapy is generally administered first. Another systemic treatment is hormonal, which uses cytostatic (cell blocking) drugs such as Tamoxifen. It is generally recommended for node negative breast cancer in pre/post menopausal women and in node positive breast cancer in post menopausal women. In addition, it has been shown to reduce the incidence of invasive breast cancer in women at high risk for developing the disease as well as those with DCIS (ductal carcinoma in situ) following breast surgery and radiation. Tamoxifen is generally well tolerated; however, approximately 25 percent of all women suffer menopausal-like symptoms including hot flashes, weight gain, vaginal dryness, nausea and vomiting. Increased risk of uterine cancer and deep vein thrombosis is noted with this drug. It is usually provided for up to five years. Arimidex is a new drug in this category, which is now recommended for hormone receptor positive early breast cancer in postmenopausal women. Fewer women have reported hot flashes, vaginal bleeding, blood clots, strokes and uterine cancer as compared to Tamoxifen. However, a higher rate of joint problems and spine, hip and wrist fractures has been noted.
Cancer is a life threatening disease that influences a woman’s quality of life and sense of self. Thus, psychological, physical, economic, social and family issues are of concern. The following are the problem areas you can expect to encounter, and they will largely determine your program design.
- Pain - After breast surgery, pain is to be expected and can be manifested in the chest, auxiliary area, shoulder and back. If TRAM surgery was performed, abdominal pain and weakness will be encountered. In addition, functional limitations such as difficulty lying on the stomach and getting up from a prone/supine position may be present with these women. Poor posture and protective posturing of the shoulder and chest due to pain contribute to poor body mechanics. You can expect to see rounding of the shoulder, forward tilting of the head, and elevation or depression of the operated shoulder with the elbow flexed and the affected arm held to the side when clients are experiencing pain.
- Range of motion - Impaired shoulder mobility can occur if exercises are not begun soon after surgery. Physicians have different protocols when shoulder range of motion is to begin. Exercise is generally recommended three to seven days after surgery has been performed or after the drains have been removed. The sooner range of motion is performed, the better. Even if shoulder exercises against gravity are not permitted, there are gentle range of motion exercises that a physical/occupational therapist can recommend. Range of motion to the elbow, wrist, and hand along with elevation of the arm should be initiated to prevent any limitations in this area and to reduce swelling. Once shoulder range of motion is permitted, it should be performed daily for at least a year. Scar tissue continues to form one to two years after surgery. It is important to stretch the pectoralis major and axillary region to prevent adhesions from forming as these limit chest and shoulder range of motion. A condition called frozen shoulder can develop if active range of motion is not practiced regularly, resulting in functional limitations and/or permanent loss of motion. A 1998 study reported that function decreased in 50 percent of the women after surgery, and 48 percent had a limitation in a least one shoulder range of motion.
- Fatigue - Fatigue is a common problem associated with all treatments but especially chemotherapy. Anemia due to decreased red blood cells may be a factor. It is the most common side effect of cancer with 40 to 90 percent of patients reporting fatigue. According to the American College of Sports Medicine (1991), after chemotherapy, the peak exercise capacity of patients can be reduced to between three to five METS (metabolic equivalents). Eight is normal.
- Weight gain - Weight gain is a common complaint for women undergoing chemotherapy. Usually a weight gain of five to 14 pounds is experienced. This is influenced by the length of treatment, node status, type of treatment and menopausal status. This weight gain is an additional stressor for women already suffering from body image issues as a result of breast surgery. It is unknown whether this is due to a reduced activity level, decreased metabolic rates or the drugs themselves. During chemotherapy, the metabolic rate decreases but then returns to normal once it is terminated.
- Brachial plexus issues - Lymph node dissection causes other problems, as the nerves that run through the axillary area and chest can be inadvertently severed during surgery. Muscle atrophy, weakness or numbness may result. The loss of the intercostobrachial nerve causes numbness and decreased axillary sweat production, especially for women who have undergone lymph node dissection. Sometimes the sensation comes back, while in other cases it may be permanent.
- Lymphedema - Lymphedema is an uncomfortable or painful build up of protein rich fluid in the arm, chest and/r axillary region. Clients may complain that their arm feels heavy, achy or numb. They will become easily fatigued when experiencing Lymphedema in the arm. Loss of range of motion can result due to these issues. Infection, scarring in the region due to surgery and radiation are all risk factors. When lymph nodes are removed, the vessels that carry fluid back to the heart may be damaged or removed. Also, radiation can inflame the area. Lymphedema can occur right after surgery or many years later. It is difficult to prevent this as many factors can cause it to develop. Lymphedema and its possibility is a constant reminder of the cancer. In addition, it can be quite disfiguring if not caught early, and it can be a chronic problem for which there is no cure. Chronic Lymphedema causes moderate to severe swelling and is usually irreversible. A new procedure entitled sentinel node biopsy may reduce the incidence of Lymphedema in the future. (Read more on Lymphedema here.)
- Osteoporosis - Osteoporosis is a great concern since the treatments can cause early menopause. Studies have shown that one year after chemotherapy, postmenopausal women frequently have a substantial drop in bone density. A 2001 study in the Journal of Clinical Oncology indicated an eight percent decrease in bone density among breast cancer survivors. Age seems to be the best predictor of who will go into premature menopause after chemotherapy. The older a woman is during chemotherapy, the more likely premature menopause will occur. Postmenopausal women should receive a bone density test to obtain a baseline measure of the risk of fractures to the wrist, hip or vertebra. Tamoxifen causes a small decrease in bone density among premenopausal women but seems to be beneficial to bone density in post menopausal women. (Read more on Osteoporosis here).
- Psychosocial issues - Psychosocial issues are normal after a diagnosis of cancer. Fears relating to death, disfigurement and dependency are common along with body image, sexual, financial and relationship concerns. High stress levels are experienced along with feelings of anger, depression, fear and anxiety. Everyone reacts differently to a diagnosis of cancer. After undergoing treatment, you will find some women become breast cancer advocates or lead support groups while others are fearful and hide it from friends, family and co-workers. It is important to know how to reach the support groups in your area and to recognize signs of depression such as failure to eat, sleep or engage in normal activities.
To conclude, breast cancer is a serious illness that requires an understanding of the disease and the problems you will most likely encounter. A decrease in the quality of life can be experienced, which has great implications for you as a personal trainer. I advise doing further research in this field to further your knowledge base. Part 2 of this series will focus on exercise goals and recommendations for range of motion, strengthening and aerobic fitness, based on the eight concerns noted above.
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