Posted by: bcconnections | September 13, 2012

Rx: Exercise

By Regan Fedric, Exercise Physiologist.  Cancer Exercise Counselor with UCSF, Smith Integrative Oncology, & The Center for Integrative Health and Wellness of Marin General. Program Director, Co-founder, Board Director, Sunflower Wellness

This article was published in the September 2012 issue of Connections, Breast Cancer Connections’ Newsletter.

I’m a believer of “use it or lose it” when it comes to the human body. The body was made to move. It simply needs to move – in any way or form. The more the better and anything is better than nothing. Without movement it becomes stiff, weak, fat, and starts to shut down. Movement on a daily basis increases energy levels, improves sleep quality, and can boost mood.  It also helps maintain a healthy heart, mobile joints, active muscles, and lean body mass. It makes us feel better, stronger, more balanced, and more connected to ourselves.  The increased connection to one’s self is the most common feedback I receive from helping women and men living with cancer when recommending that they begin safe and effective exercise routines. A sense of control is regained through adding and/or maintaining an active lifestyle.

Several research studies have demonstrated the benefits of exercise for breast cancer survivors.  Physical activity improves quality of life and body composition, reduces breast cancer recurrence, and decreases breast-cancer-specific mortality (Ogunleye and Holmes, Breast Cancer Research, 2009;11:106-8).  The Nurses’ Health Study found that women with early-stage breast cancer who performed moderate exercise for three to five hours per week had half the risk of breast cancer returning and half the risk of dying from the disease, compared to women who performed less than one hour of moderate exercise per week (Holmes et al., JAMA, 2005;293:2479-2486).  Furthermore, a study conducted by researchers from Yale University and  Dana Farber Cancer Institute found that a six-month aerobic exercise intervention decreased body fat, increased lean mass, and maintained bone mineral density in breast cancer survivors (Irwin et al., Journal of Obesity, 2009;17:1534-1541).  Aerobic fitness may also have an impact on the survival of women with advanced breast cancer.  According to researchers at Duke University Medical Center, among women being treated for metastatic breast cancer, those who had higher levels of aerobic fitness tended to live longer than those with lower levels of aerobic fitness (Lee et al., Journal of Clinical Oncology, 2012;30:2530-7).

These and other research findings are compelling and provide strong motivation.  Exercise during active treatment and post-treatment is now strongly encouraged for cancer patients. Dr. Kerry Courneya, a researcher with the Canadian Cancer Society, stated during an education session on exercise and cancer at the 2011 American Society of Clinical Oncology meeting, “We’re finding that patients can do a lot more than we originally thought they could do, even when they’re on chemotherapy or radiation therapy.” I find this to be true and have seen an increase in interest among patients, and medical oncologists are increasingly advising patients to exercise. These are two key factors in the growth and development of this emerging field.

In 2010, “Exercise Guidelines for Cancer Survivorswere released by the American College of Sports Medicine (Schmitz et al., Medicine & Science in Sports & Exercise, 2010;42:1409-1426).   A panel of 13 experts came together to review and publicize the underlying message: AVOID INACTIVITY. The guidelines below are based on the US Department of Health & Human Services Physical Activity Guidelines for Americans (

When it comes to exercise, start where you feel comfortable, and start sooner than later.  Our life paths are all unique and we have different experiences and exposure to exercise. We find motivation in different ways. There is not a single format to the perfect exercise program. There is no quick fix either. It is a commitment that requires discipline and dedication. Exercise needs to be prioritized – we must value it and learn to schedule time to make it happen. Participating in a variety of activities is a great way to increase motivation and overall adherence. Changing your routine is a safe way to support your body and decrease the breakdown of joints due to repetitive motion.

Seek help from a qualified professional. The health and fitness industry is constantly changing as we learn more from science and research. An emerging field of physical therapists, personal trainers, and nurses is learning more about cancer and exercise. There are several “Cancer Exercise” certifications and educational programs across the country. In some communities there are specialized programs and classes for cancer survivors. It is important to communicate your goals, needs, concerns, and limitations to any private or group instructor before beginning an exercise session. YOU are in control of your body and must be aware when adding new activities or progressions to an exercise program. Listen to your body and modify your activities as needed.

Below is a list of program recommendations to assist during different phases of treatment:


Perform range-of-motion patterns for the shoulders. Focus on opening and stretching the chest. Strengthen the back and postural muscles.  Continue with your aerobic exercise routine, or start something manageable, such as walking at a moderate pace for a minimum of 10-15 minutes on as many days per week that you can.

Following Surgery:

Always seek medical clearance from your surgeon before resuming or beginning any exercise routine.

Depending on the extent of surgery and ease of tissue recovery, resume normal activities once you have full range of motion with the affected side and shoulder joint. Walking is a great starting point and can usually be done a few days after surgery. Typically 10-14 days out, the tissue has healed and range-of-motion exercises are encouraged. Similar to pre-surgery recommendations, you should focus on shoulder range of motion, opening the chest, and strengthening the back to help support good posture. I often recommend a foam roller and series of dynamic arm/shoulder patterns to assist with recovery and postural corrections. Once joint range of motion is recovered, it is safe to begin a weight-training program.

During Chemotherapy:

Do the best you can. Try to be more active on your “good” days or weeks, and maybe even push a little harder just because you can. On the “bad” days aim for shorter bouts, gentle walks, and a five-minute “get out of bed” routine.  On days when you do not feel like doing anything, take some time to relax. Take a few deep breaths and know that it will pass. Do anything you can to support your system with increased oxygen and blood flow. Walking is a great activity and can be done anywhere–call a friend or ask a family member to join you.  Stretching and working on your flexibility can be a great way to continue your activity, even in bed, and with much less effort than aerobic exercise.

During Radiation:

Regular exercise, especially aerobic exercises such as moderately-paced walking, can help decrease radiation-induced fatigue. Range-of-motion/flexibility exercises are great to help support the chest and shoulder joint, especially if you begin to feel tight or restricted with movement. Range-of-motion activities also help support the lymphatic system. Creating more space and movement can help the nodes flush or move lymphatic fluids. Aerobic exercise will support the body and tissue by increasing overall oxygenation in the body.

Lymphedema and Exercise:

Exercise does not cause lymphedema, and several studies are now showing that it can actually prevent its development (Kwan et al., Journal of Cancer Survivorship, 2011;5:320-36, Schmitz et al., New England Journal of Medicine, 2009;361:664-73, Schmitz et al., Journal of the American Medical Association, 2010;304:2699-705).  If you have lymphedema, or are at high risk for developing it, see a physical therapist for manual lymphatic drainage, measurements, and advice on a sleeve or arm wrapping.  Seek advice and guidance from qualified professionals about a safe exercise routine.  Swimming is a good activity for those at risk for lymphedma, as long as there are not any skin or tissue problems from other procedures.

When lifting weights, use light weights and perform many repetitions on major muscle groups.

Alternate upper and lower body exercises.  Focus on dynamic movement patterns and compound muscle group exercises, rather than isolated exercises and small muscles of the arms. For example, use a cable tower or resistance band and perform a standing one-arm back pull with a side step or lunge. This creates more for the body to manage, as opposed to sitting and doing only the one-arm back pull.  It’s recommended to progress slowly with increases in weight and changes to your program.  Perform range-of-motion exercises or stretch following your session.

For Prevention and Treatment of Bone Loss

Treatments for breast cancer can have a significant negative impact on bone health.  Exercise may be an effective therapeutic intervention for treatment-related bone loss, but sufficient clinical evidence is lacking to support specific recommendations for breast cancer survivors.  The American College of Sports Medicine generally recommends that women preserve bone health in adulthood by participating in weight-bearing endurance activities (jogging, stair-climbing, tennis) and activities that involve jumping (volleyball, basketball) three to five times per week, and resistance exercises that target all major muscle groups two to three times per week (Winters-Stone et al., Cancer, 2012;118:2288-99).



Sunflower Wellness:

Living Strong Living Well, A Strength/Fitness Program for Cancer Patients & Survivors:

Yoga Bear’s list of free Yoga classes for cancer survivors:

PJCC’s Pink Ribbon Program:

Search for a Cancer Exercise Specialist:


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