Study: Research suggests exercise is safe for breast cancer patients at risk for lymphedema


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Patients and health care providers are often concerned about how exercise affects lymphedema (swelling in the arm or hand) in breast cancer survivors or other women who have had lymph node biopsy at the time of mastectomy. Research on this topic has been mixed. A new study suggests that exercise after breast cancer treatment does not lead to lymphedema or worsen existing lymphedema. However, because this study was small, more work needs to be done to understand the relationship between exercise and lymphedema in cancer survivors. (2/22/17)

STUDY AT A GLANCE

This study is about:

How exercise affects lymphedema (swelling in the arm or hand) that can occur after breast cancer treatment.

Why is this study important?

Over the years, research on the relationship of exercise to lymphedema has had mixed results; some studies suggested that exercise could cause cancer patients to develop lymphedema or make their current lymphedema worse, while other studies found that a gradual exercise program helps patients with lymphedema.

Study findings: 

After 6 months of resistance exercise training, the extent of lymphedema did not change significantly.

What does this mean for me?

This study suggests that women who have been treated for breast cancer can perform moderate-intensity exercise (including aerobic and strength exercises) without developing lymphedema or making their existing lymphedema worse. However, as other research studies in the literature contradict these findings, more work is needed to fully understand the relationship between exercise and lymphedema development. Breast cancer survivors and women who have had mastectomy should report any symptoms of lymphedema to their health care providers, and consult with them before beginning any type of exercise program.

Expert Guidelines

The National Comprehensive Cancer Network (NCCN) has recommendations on physical activity for people diagnosed with cancer. 

  • Physical activity and exercise recommendations should be tailored to the individual’s abilities and preferences
  • Physical activity for cancers survivors:
    • Overall volume of weekly activity sould be at least 150-300 minutes of moderate-intensity activity or 75 minutes of vigorous activity or equivalent combination spread out over the course of the week
    • Two to three sessions per week of strength/resistance training that include major muscle groups
    • Stretch major muscle groups at least two days per week
  • Engage in general physical activity daily (eg. Taking the stairs, parking in the back of parking lot)
    • physical activity includes exercise, daily routine activities, and recreational activities
  • Avoid prolonged sedentary behavior (eg. Sitting for long periods).

NCCN also has guidelines on lymphedema. According to NCCN:

  • Lymphedema is most common within 18 months of treatment but can develop anytime in the life of survivors.
  • Surgery or radiation to lymph node areas increase the risk for lymphedema. Sentinel node biopsy can also increase the risk of lymphedema although less risk than complete lymph node dissection or radiation. The risk goes up with obesity or as additional lymph nodes are removed.

NCCN recommends the following:

  • Limbs should be measured pretreatment on both sides to establish a baseline for survivors. Ideally measurement should be performed by lymphedema specialists.
  • Early detection is important because early-stage lymphedema is more likely to be reversible than later stage lymphedema. Therefore survivors should be told about the signs to look for including:
    • Swelling, tightness, heaviness, or pain on the side of treatment.
  • Because of the increased risk for infection in areas affected by lymphedema, survivors should be told to contact their providers if they see any signs of infection in affected areas.
  • Progressive weight training under supervision and physical activity do not worsen lymphedema.
  • According to NCCN, air travel. blood pressure measurement, and blood draws have not been proven by research to cause or worsen lymphedema. More research is needed. Until then, if possible blood draws and blood pressures should be done on limbs that are not at high risk.
  • Providers should ask their patients about any changes or symptoms of lymphedema at each visit.

For patients with symptoms, NCCN recommends:

  • Ruling out recurrence of cancer
  • Refer to a certified lymphedema specialist if available to assess, stage and plan treatment lymphedema

Lymphedema treatment includes:

  • Survivor education on self-care management
  • Referral to a certified lymphedema therapist if available for:
    • Compression garments
    • Supervised exercise
    • Manual lymphatic drainable

Patients in treatment should speak with their providers about their exercise programs. 

Questions To Ask Your Health Care Provider

  • I recently completed breast cancer treatment; am I ready for an exercise program?
  • I had breast surgery to treat breast cancer; what types of exercises are right for me?
  • Am I at risk for lymphedema after breast surgery or radiation?
  • What are the symptoms of lymphedema?
  • What should I do if I notice swelling in my arm or hand?
  • How can exercise affect lymphedema?
  • Are there ways to reduce the adverse symptoms of lymphedema? 
  • Besides lymphedema, what other side effects of breast cancer treatment should I know about?

Open Clinical Trials

 
 

IN DEPTH REVIEW OF RESEARCH

Study background:

Lymphedema, a swelling of the arm or hand due to lymph node damage, is an adverse side effect that often occurs after breast cancer treatment. Currently there is no cure for lymphedema. Patients who develop this condition can ultimately experience symptoms such as changes in sensation in the arms, a greater feeling of fatigue, and decreased quality of life. Other side effects of breast cancer treatment include decreased bone health and increased fat mass. Strength or resistance exercises can help patients to improve their bone health and weight gain that may occur.  However, some research suggests that resistance exercise may cause patients to develop lymphedema or make it worse.

Emily Simonavice and colleagues from the School of Health and Human Performance in George College and State University and other institutions studied the effect of resistance exercise in women who were treated for breast cancer; their results were published in the journal Supportive Cancer Care. This is one of several recent studies that suggests that strength exercise is safe for breast cancer survivors and does not cause lymphedema or make existing lymphedema worse.

Researchers of this study wanted to know:

How does exercise affect lymphedema in women who have been treated for breast cancer?

Population(s) looked at in the study:

  • Study participants included 25 women who:
    • had breast cancer between stages 0-III
    • completed all primary treatments (surgery, radiation, and/or chemotherapy) at least 6 months before the study started
  • Initially, 27 women began the study, but two dropped out due to clinical complications unrelated to lymphedema. However, data from these women while they were in the study were collected and included in the results.
  • Three of the women already had lymphedema when the study began.
  • Each woman had 2-hour, moderate resistance exercise training sessions per week, which included an aerobic warm-up and exercises targeting all major muscle groups (such as chest presses, leg presses, biceps curls).
  • The presence and/or extent of lymphedema was determined by measuring each woman’s arm circumference every two weeks.

Study findings: 

  1. After 6 months of resistance exercise training the extent of lymphedema did not change significantly.

Limitations:

These findings are preliminary because this study did not include a control group. Although all of the women included in the study performed the moderate resistance training, the researchers could not compare lymphedema between women who did and did not exercise (no information was available regarding the arm circumference changes of breast cancer survivors who did not exercise over the same period). It was also a relatively small study: just 27 women. Additionally, the study included only 3 women who already had lymphedema; too small to generalize the findings to all women with lymphedema. Another reason that this study cannot be generalized is because participants had different combinations of surgery, radiation, chemotherapy, and lymph node dissection (not all women had all four treatments). Finally, the study also looked only at breast cancer survivors. The effects of exercise on previvors after risk-reducing mastectomy due to a mutation in BRCA or other gene that affects cancer risk is not addressed by this study.

Conclusions:

This study suggests that women who have been treated for breast cancer can exercise without developing lymphedema or making their lymphedema worse. Because of the study’s limitations, however, more work needs to be done to fully understand the relationship between exercise and lymphedema. Other researchers have explored this area—a 2009 paper in the New England Journal of Medicine by Dr. Kathryn Schmitz from the University of Pennsylvania School of Medicine showed that breast cancer patients with existing lymphedema who did resistance exercise had greater improvements in the severity of their self-reported lymphedema symptoms compared to patients who did not exercise. Another recent report of preliminary findings presented at the Cancer Survivorship Symposium Advancing Care and Research in 2017 found no difference in the rates of lymphedema between breast cancer patients who exercised and those who did not.

All women who undergo breast surgery and/or radiation to treat breast cancer or reduce the risk of breast cancer are at risk for lymphedema; having axillary lymph node dissection increases that risk.

Current breast cancer survivorship care guidelines from the American Cancer Society and the American Society of Clinical Oncology recommend that health care providers refer patients with arm swelling or other symptoms of lymphedema to a lymphedema specialist who can recommend appropriate treatment. These guidelines also note that more research is required to develop clear evidence-based recommendations to prevent lymphedema after breast surgery and/or radiation.   Patients concerned about lymphedema should discuss symptoms with their health care providers to determine what treatment or prevention measures are best for them.

Posted 2/22/17

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