January 2006: Physical Activity and Breast Cancer


Ask-the-Expert Online Conference

On Wednesday, January 18, 2006, our Ask-the-Expert Online Conference was called Physical Activity and Breast Cancer. Miriam Nelson, Ph.D., Julie Gralow, M.D., and moderator Judith Sachs answered your questions about the many issues related to physical activity and breast cancer.

Exercise prevents cancer, recurrence?

Question from DeborahL: Is there a difference between the effect of exercise on getting breast cancer in the first place and the effect in preventing a recurrence? I have always been physically fit and still got breast cancer but I am wondering if my continued exercise (which I would do anyway) will help prevent a recurrence.
Answers - Miriam Nelson We do know from observational trials that there is a reduced risk of getting breast cancer in individuals who are physically active. That doesn't mean that if you are physically active, you aren't going to get breast cancer; it just means that it's a relative risk. The same is true for individuals who get breast cancer—they can reduce their risk of recurrence by being physically active. At least, that's what the data suggest at this point. By all means, you should stay physically active. You should also be eating well and taking as good care of yourself as possible.
Julie Gralow, M.D. With respect to reducing the risk of getting breast cancer, I absolutely agree with Dr. Nelson. There is increasing evidence that we can reduce the risk, but there's no guarantee of prevention of getting it. It's possible that in your exercising you may have delayed the onset of the breast cancer. I say that because in an important study called the New York Breast Cancer Study of BRCA1 and BRCA2 gene mutations, among the patients who ultimately got cancer, those who did physical activity and maintained a good body weight in their teens and 20s had a significantly later age of diagnosis than women who reported a sedentary lifestyle in their 20s and 30s. So the exercise you did may have delayed the onset of breast cancer.

Will exercise now reduce the risk of recurrence? There is an interesting recent study just published less than nine months ago, the Nurses' Health Study, that suggested after a diagnosis of breast cancer, exercise can reduce the risk of recurrence. It looks like for women who just walk at an average pace three to four hours a week, we saw reduction in deaths from breast cancer. It's encouraging that there may even be less recurrence and death from breast cancer by exercising.
Judith Sachs In these studies, it seemed the greatest benefit was to have a BMI (Body Mass Index) under 25. Can you talk a little about how exercise affects weight maintenance, and how it's important to get the BMI down?
Miriam Nelson Being overweight and obesity are having a major impact on so many aspects of our health. It's not just on heart disease, diabetes, arthritis, quality of life; it's also on breast cancer and cancer in general. Many people are trying to figure out what the link is. The fact that 65% of women now are overweight or obese is putting them at a much higher risk for breast cancer. The weight control is a primary concern around cancer prevention. You can't just control your weight—you don't just flip a switch. The combination of focusing on good food choices and also increasing physical activity so you get an energy balance is quite simply what you need to do.

It sounds very simple to eat better and exercise more, but we are creatures of habit. Our bodies are programmed to not lose weight because we don't want to get into starvation mode. Our bodies have a strong appetite, a love for food. With modern society, we have created an environment in which almost all of us live in a way that we expend very little energy, so we have to be conscious when we are trying to expend more energy.

Our environment is stacked against us also, with the plethora of highly palatable foods that are available. Only 30 years ago, a typical supermarket would have 1,500 food items for sale. Now it has 40,000-60,000 to choose from. It used to be a very special occasion to eat out, but now 50% of Americans eat out at least once a day. So you can see our worlds have collided to really make all of us overweight, unless we are diligent and conscientious and have a social structure of support that allows us to eat better.

When we are more active, we burn more calories, and if we eat a little bit less or even the same (which sounds easier than it is), we will lose weight. The problem is that our appetite regulation is finely attuned, so if we burn more calories we feel like eating more so we have to consciously try to not eat more when we're exercising. But there are more benefits from exercise than just increasing metabolism. When we use our muscles, we stimulate them and that increases our resting metabolism. We also increase endorphins, which gives us a better sense of well-being and makes us happier. All of these factors help with weight control. I like to say it's not rocket science, but energy balance is much MORE complicated than that! We're programmed to gain weight, not lose it.

Suggested exercise for lymphedema?

Question from Deborahann: I am recently diagnosed with lymphedema in my left arm and truncal lymphedema on my left side. I am concerned about the amount of exercise I can safely do without causing further discomfort to myself. I love to walk, hike and cycle and infrequently lift weights. What would you suggest as the best form of exercise to engage in now?
Answers - Julie Gralow, M.D. My general recommendation for my patients is to speak to a physical therapist who really understands. I encourage physical activity, and have many patients with lymphedema who do dragon boating and light weight-lifting. They tell me certain physical activities help the lymphedema, but I'd strongly encourage getting help from a physical therapist trained in this area. You can do harm in the short term. It's not uncommon for a little bit of an increase in fluid, and fluid can be seen transiently after some of these exercises. You need to pay attention to the cues your body gives you and cut back if you're doing too much.

One cue to watch for is whether the fluid goes quickly with gentle massage, in which case I don't think there's serious damage. But if the fluid doesn't move easily and it seems to tip (the dent you make with your finger stays there for a while), that would be a cue, especially if after exercise, that you want to pick a different activity. If you're getting a lot more pain after you've done a particular activity, that is something that's important to tell your physical therapist and health care team because it could be a sign there's something happening that we should not be pushing.
Miriam Nelson I agree completely. What's important for women to realize is that even though you may have a condition where you may have to limit certain exercises, your whole body still needs to be fit and healthy. You need to find an exercise that your body does well and that you enjoy. If you become more sedentary, it's likely you'll gain weight and put yourself at risk for heart disease and possibly risk of recurrence.

So you need to find the activity you enjoy and that your body tolerates. We've done a lot of work with women and strength training where I work, and a number of women have had lymphedema that's been transient and controlled. They have done exceptionally well with dragon boating and with strength training, both upper and lower body. Because of this, it doesn't mean you can't lift weights or do these exercises; you just have to follow the lymphedema carefully.
Judith Sachs Could one of you describe dragon boating for us?
Julie Gralow, M.D. Dragon boating is really an Asian sport, and at least in the Pacific Northwest it's quite popular, not just among cancer patients, but as a general activity. The dragon boat, as we've evolved it in Canada and the US, holds about 20 rowers sitting two by two. There's a tiller in the back guiding, and in the front is a drummer or someone beating in rhythm. It's really quite physically active. We have a group here in Seattle called Team Survivor Northwest that has an active program. They take part in competitions, including cancer competitions. There are lots of teams from different cities here in the Northwest.

When you're really in a heat, and you're rowing fast, you can't keep it up for more than a couple of minutes. It's very aerobic. It's a great team sport, which is why many of our women cancer patients like it. Some people are into individual sports, like running while listening to music, but others would rather have that community feeling. It's a support group of sorts when you're out there with other cancer survivors. It's very motivating to be part of a group like that. You have to show up because if you don't have all the 20 people on the boat, especially in a competition, you don't even get to compete. You're committed to other people, so you do it.
Miriam Nelson It's lots of fun to watch too!

Exercises to counteract bone loss?

Question from DonnaMS: I'm BRCA2 positive and have had a bilateral mastectomy (with nodes removed on one side) and a hysterectomy. I'm currently on Arimidex, and since I'm only 43, am concerned about bone loss. In addition to taking calcium, what specific exercises should I be doing to counteract the effects of bone loss? Can I do weight-lifting (weight bearing) exercises due to the removed nodes and the risk of lymphedema?
Answers - Miriam Nelson You should talk to your health care provider if possible before you get started. You're so young and your bones are young, so the best thing you could do is start with gentle weight lifting, and progress from there. Monitor your progress and see how you do.

Strength training along with walking seems to be the most potent type of activity for improving bone health and reducing the risk of fracture. We have a lot of information and free resources at our website, http://www.strongwomen.com. Calcium is very important, and any women over the age of 40 should consider taking a calcium supplement, but Vitamin D is equally important and many women haven't got the message yet about how important it is. Eating well — lots of fruits and vegetables — is good for your bones. Don't smoke, of course, and don't drink more than one alcoholic drink a day.
Julie Gralow, M.D. With respect to the calcium, it's great that Dr. Nelson mentioned Vitamin D to help calcium absorption. If you are postmenopausal, about 1,500 mg of calcium a day is recommended. If you take it all at once, you absorb it less than if you split the dose into three times a day. What I find works best is chewable calcium, and I keep it with me in my purse or pocket. A couple of times a day, I take some and chew it to get more absorption and in the chewable form, I'm more likely to take it. So some good calcium, Vitamin D, and weight bearing exercise will help.

Following the bone density and knowing where you stand is important, so periodically ask your doctor to do a DEXA scan to see where the bones are compared to other women of your own age. That way you can get a sense of what your fracture risk is and how much work needs to be done.

Sometimes we do have to take medication from the drug family called bisphosphonates to increase bone density. So, a woman in her 40s taking Arimidex might benefit from a drug in this class, and the way to tell would be to do a DEXA scan every year. It's clear that the treatments we're currently giving for breast cancer are becoming more and more effective, but they're causing more and more osteoporosis. So it's great to survive your breast cancer, but not to reduce your bones and get a hip fracture at a young age.
Judith Sachs I know there is a calcium chewing gum. Does it really work?
Miriam Nelson Calcium comes mainly in two different formulas: calcium carbonate or calcium citrate. Both of those types of calcium help the bones. So it doesn't matter if it's chewable or in a gum or orange juice or a supplement. The difference is that calcium citrate is generally absorbed a bit better than calcium carbonate. You also don't need to take calcium citrate with a meal. One of the better benefits is that you don't get gas with calcium citrate, and a fairly large percentage of women do get gas from calcium carbonate. All calcium helps with bones; a lot of it is how you take it and what you tolerate best.

Limited exercise for PICC?

Question from Cor: What specific exercise limitations are there with a PICC (peripherally inserted central catheter) line? I was told watch "heavy lifting" and "repetitive movement" but couldn't get any clear answer regarding what that actually meant.
Answers - Julie Gralow, M.D. The main thing is that you don't want to be doing a bunch of jarring motions that could potentially move the line up and out of the body. Obviously the PICC line is there to make it easier to draw blood and receive the chemotherapy. PICC lines can be put in different places, but they usually come out in the upper or middle arm.

It's a bit of a cop out to say "use common sense," but I would not use that arm vigorously. With a PICC line in place, I wouldn't try to lift. But I would discourage complete disuse of the arm. If you really protect it a whole lot, that would also not be a good thing if the muscle atrophies. I know you were asking for specifics, but just avoid very vigorous activities or things that hurt.

How long to recover before marathon training?

Question from Nosweat: I used to run marathons (slowly). Now during chemo I can hardly run/walk 3 km. How long is realistic to expect recovery to take after chemo, surgery and radiation before I will be able to train hard again?
Answers - Julie Gralow, M.D. First of all, I want to make sure that you aren't being too hard on yourself. I normally tell my patients that during breast cancer treatment to expect an average of 60% of your normal energy level. Sometimes it will be less, sometimes more. That's number one: give yourself flexibility, but keep trying. Once you're finished with your treatment, a lot of people and their families think the hard part is over and you should be okay now.

I try to make clear up front that it takes at least six months to a year to regain the point where you were before you started all this treatment. Especially if you really had to back off in your training, you lost a lot of ground. But in six months you should be starting to get back to normal. Use a heart rate monitor to make sure you're not pushing yourself too much—about 65% of your maximum heart rate—and don't try to go too much above that. But once you're finished your treatment, you can start pushing your heart rate up again.
Miriam Nelson I'm a marathon runner, so I empathize. I think sometimes people are way too tough on themselves. They're going through a major medical issue that is impacting them physically and emotionally, as well as mentally. Their bodies have become very de-conditioned, and they're not used to that. They're used to being able to just go out and run and train hard. So first, be kind to yourself.

Once everything is finished and you're on the road to recovery, you need to come up with a schedule that has to be revised here and there, depending on how you feel, that progresses in terms of mileage over each week very slowly. So you think of it almost as a year, in terms of really getting back and feeling like you used to. That's probably a good rule of thumb. It will kick back in, but you have to give yourself time. The other thing is that your progress may not come back in a linear fashion. It may be you're training and one week you feel better, but then it's another two to three weeks before you feel better than that. So slow progression and listening to your body is the best thing you can do.
Judith Sachs Both doctors have made interesting points that exercise improves emotional fitness as well as physical. Exercise is something that increases your self-esteem and makes you feel good as a person, so not being able to do as much as you're used to can lower your self-esteem. Sometimes people who have been marathon runners or weight lifters may want to step back and look at less strenuous exercises, like yoga or tai chi. Yoga can be done with props, so if you're fatigued you can get support from a bolster, block, or strap as you do the movements, yet you still get benefit in flexibility and balance and breathing that happens with these less aerobic activities.

Survival rates increased by exercise?

Question from Steph: I know there have been studies done showing the effects of exercise on survival rates in women with Stage I, II, or III breast cancer. I'm a survivor with Stage IV breast cancer, and I'm assuming the same exercise would be very beneficial to me (I have my doctor's okay) but I was wondering if any studies had been done on survival rates or quality of life for Stage IV breast cancer patients. Thank you.
Answers - Julie Gralow, M.D. With respect to improving survival in Stage IV breast cancer, I know of no studies that have looked at it. I don't know how to answer that. With respect to the other benefits RE: quality of life, absolutely that has been studied in all stages and there have been benefits with respect to anxiety and sleep patterns. I'm talking Stage IV as well as other stages, and with respect to other stages, fatigue has been studied. Some studies suggest less nausea and pain with exercise. So there are lots of reasons to do it, even in a metastatic setting where I can't promise it will increase survival, but it will make you feel better along the way.
Miriam Nelson My sense is that we actually haven't had good trials with Stage IV breast cancer and exercise in terms of survival. In order to do these types of trials, you need large numbers of people and they're very expensive, so there's not a lot of research in this area. So it's not that we looked at it and it didn't help; it's that we haven't looked at it yet. I think there is every reason to continue exercising.

Treatment inhibits healing from other surgeries?

Question from CBF: Can being a being a post-cancer surgery patient affect healing of other parts of the body? I had a knee cartilage repair over a year ago and still have not been normal enough to return to a healthy level of activity. The surgeon is frustrated with the healing problems. Could it be auto-immune problems? Aromatase inhibitors or other drugs? Would human growth hormones work?
Answers - Julie Gralow, M.D. If chemotherapy was given, there is an impact on healing in general for months after the chemo, but this sounds like it's been longer than that. Aromatase inhibitors have been shown in studies to cause muscle and joint aches, and we don't understand the mechanism of that. I don't think we have data to suggest the aromatase inhibitors inhibit healing. I don't think there is data that would support the use of human growth hormones for this problem, and I doubt that having treatment for breast cancer would increase the chance of having an auto-immune disease. Of course, just because you have had breast cancer doesn't mean you couldn't develop an auto-immune disease as an unrelated problem.

Exercise benefits differ for ER- vs. ER+?

Question from Crimson: How does the value of exercise differ if your breast cancer is estrogen-receptor-negative vs. positive?
Answers - Julie Gralow, M.D. In the Nurses' Study, they did look at estrogen receptors. and there was a trend towards more benefit in the women whose cancers were ER-positive. This doesn't mean there was not benefit in the patients who had ER-negative cancers.

Interestingly, talking about healthy lifestyle in general, there was a very important nutrition study that was done in women within a year of their diagnosis of breast cancer. It was called the WINS Study (Women's Intervention Nutrition Study), and they randomized women to receive nutritional counseling that primarily focused on a low-calorie, low-fat diet vs. standard of care. The counseling was just every two weeks with some literature backup.

At one year they proved the women who had had the counseling were eating less fat and had gained less weight. At five years, the study showed there were fewer breast cancer recurrences in that group who had gotten the counseling on a healthy diet. In that study, when you broke out the estrogen-receptor-positive and negative cancers, the benefit of the nutritional counseling seemed greater in the ER-negative group. I'm not sure that makes sense, so there might be some other explanation. I just encourage all my patients, no matter what, to eat healthy and get some physical exercise. Until we get this all straightened out, I'll recommend that to all patients.

Post-reconstruction exercises?

Question from MAbrams: I had Stage III breast cancer in 2003. I just completed my last reconstruction. What is some good information about beginning to exercise after TRAM flap and post-op implant surgery? I am fighting fatigue but have access to a gym.
Answers - Miriam Nelson You should certainly talk to your physician and make sure you get the okay for moving forward. It can be really beneficial to work with a professional—a physical therapist or a certified personal trainer who has worked with breast cancer patients. But you could do it on your own as well.

Be cautious and smart to begin with. Start with an easy program. Some aerobic activity and some mild weight exercise is the best thing you can do. You don't just run a marathon the next week—you slowly get fitter so all your muscles (especially your abdominal, back, and core muscles) improve. Over time, the muscles, ligaments, etc. will all become fitter as will your cardiovascular system. A lot of it is being smart, going back to our theme of common sense. Also, come up with a smart plan. Write it down, and keep track of how you feel, periodically reevaluate your fitness goals, and move from there. The hardest thing for anybody (it doesn't matter who you are) is to be consistent with your exercise. That's where things like a pedometer, or a journal where you keep track with self-monitoring can be very helpful.
Judith Sachs In terms of physical evaluation, is it true you can get your doctor to prescribe a physical therapist or trainer?
Miriam Nelson It depends on what is covered by your health plan.
Julie Gralow, M.D. The majority of my patients usually are allowed some physical therapy benefits, say six to eight visits. Sometimes I'm successful in getting that extended, if I can prove it will help.
Miriam Nelson If you do meet with a physical therapist and you only have six visits covered, the most important thing is for them to help you get a fitness plan for yourself after you finish, so they've trained you enough that you know what to do and how to progress.

Pilates and yoga suggested for survivors?

Question from Gail: Are Pilates and yoga good forms of exercise for breast cancer survivors?
Answers - Miriam Nelson I'd say that any exercise is good for breast cancer survivors. The exercise that you are going to enjoy the most and stick with the most is probably the best exercise that you can do. When you talk about being more specific about the benefits, yoga, tai chi, and Pilates are all helpful for women, whether you're a breast cancer survivor or not, because they help with strength and flexibility especially at the core, the abdominal and back muscles. Women tend to be weaker than men in these areas, so these types of exercise are excellent. The only thing I'd add is that if you have particular issues, i.e. lymphedema, you need to be a little more cautious.
Julie Gralow, M.D. I would just add that I like the strength building of yoga and Pilates. Having done some of this myself, I know you can get major benefits. When my patients enroll in a program when they're doing this twice a week for eight weeks, they always feel stronger at the end.
Judith Sachs As a teacher of tai chi, I want to put in a plug for that. Arms are held in the air as the body moves, and it's wonderful because there's no resistance to anything except the air. For somebody recovering from upper body surgery, it's a non-dynamic way to learn to use the arms again.

Strength-training for busy mom?

Question from HJ: My breast cancer has metastasized to my bones. I am on Femara and Zometa. I am 40 pounds overweight and other than my weight and breast cancer am in good health. I am 44, mother of three, and struggle with getting an exercise program in place. I need to do something I can do that does not add stress to my life. I love to walk, but not in the cold (I live in Minnesota). I would like to have a strengthening routine I can do at home.
Answers - Miriam Nelson I'm the strength-training queen! You've come to the right place. First, you need to make sure you're doing everything you can to take care of yourself. Make sure you have the social support you need, and you can certainly do the strength training at home. Look at my first book, Strong Women Stay Young as well as information on the website, http://www.strongwomen.com. There's another website we developed, http://nutrition.tufts.edu/research/growingstronger, and that's a home-based strength training program that you could do on your own. It's animated, and there's a PDF file you can print.

Having said all this, it can be enormously helpful to get a professional in, such as a good personal trainer who's worked with individuals with chronic conditions and who can help customize your program and make sure you're doing the exercises correctly. But because of the issue you also have with weight control, if at all possible you need to be getting some aerobic activity as well In the very cold months, try (literally) dancing! Dance with the kids—put a CD on and move. Or find a class where you can go. The combination of strength training and aerobic activity will be much more helpful with weight control.

Exercises for flexibility and muscle tone?

Question from Helen: I have metastases to the bones all over the body but I feel I should do some exercising to keep the flexibility and some muscle tone to cope for longer. Where should I go for suggestions?
Answers - Miriam Nelson I would suggest yoga, tai chi, or Pilates, just in terms of helping with well-being as well as strength and flexibility and getting to the whole body. Hopefully there is a fitness center or YWCA near you that has programs.
Julie Gralow, M.D. In somebody who has known metastases in the bones, it is important to talk with your oncologist and know where the spots are and whether the spot's at increased risk of fracture. Make sure your health care team is aware of your fitness regimen.

I think some oncologists are overly cautious in their recommendation to patients with cancer in the bones. Being involved in Team Survivor Northwest as their medical director, I have many patients with metastases to the bones who are very physically active. I have a team that participates in a triathlon every year. One year I had a woman who was training, and her oncologist called me and said she shouldn't be doing so much because of her bone metastases. I asked if any spots were at increased risk of fracture, and when told they weren't, I said I'd watch the woman to make sure she didn't have problems.

Indeed, when she completed the triathlon, her husband was one of the volunteers, and it was a great thing. She only lived a couple more months after that, and at her memorial service, her husband told me how much we were able to do for her in her last couple of years of life to allow her to participate and set goals, and when she crossed that finish line, it was her greatest accomplishment in the last couple of years. He thanked me for allowing her to participate when her oncologist had been so hesitant.
Judith Sachs The power of the human spirit is so much stronger than we ever imagined!
Miriam Nelson Many times, physicians are very cautious about exercise because they really don't understand the benefits, and they're worried just about the risks. Not always, but almost always, some exercise is much less risky than no exercise at all. I think you do need to be proactive as a patient.

Water aerobics helpful in weight loss?

Question from Mamat: I have gained 25 pounds since my mastectomy in August 2003. I do water aerobics and tried Pilates, which was too tough for me. I am 75.
Answers - Miriam Nelson In terms of weight control, water aerobics is helpful but land exercise will probably have more impact: walking, dancing, activities where you're burning more energy. But then, the science shows us right now with long-term weight control that physical activity is crucial, but if women don't address eating more healthily and taking in fewer calories, weight loss doesn't happen. There is a lot of debate right now about the contribution of nutrition and physical activity to weight control. I think it's 50/50, but some think 75% is about appetite suppression, food choices, and the environment of the people—where they shop, where and when they eat, etc. Any time weight control is an issue, you really have to look at nutrition as well.

Recommendations for using weights?

Question from Cor: Are there any recommendations for weights—free weights, resistance bands, weight machines, soup cans?
Answers - Miriam Nelson Don't go with soup cans! Your health and the fitness program you're putting yourself through is very valuable, and your time is very valuable, so you want to do it right and get the most benefit from it. There are four common ways you can strength-train.

One is with machines or weight stacks. You can also use free weights like dumbbells and ankle weights. You can use exercise bands, like the Thera-Band, or you can simply use your body weight, such as a sit-up, a modified push-up or squat, or different activities like a lunge, where you use your own body weight. The interesting thing with weight stacks is that because they put you into proper positioning and your body is stabilized, you can generally lift more weight with weight stacks than, for example, with free weights.

But free weights have a benefit, because you have to think about your body alignment, stability, where your joints are, your balance, etc. So you get a whole other training effect with the free weights, and you get the strengthening benefit you don't get with a machine. The Thera-Band can be used, especially for upper back and shoulder exercise. But the gains in strength are generally lower than they would be with machines or free weights. (The Thera-Band web site is available at: http://www.thera-band.com.) Body weight exercises are excellent, but they tend to be more difficult. Many women don't have enough strength to start out with them. That's the premise of tai chi, too—it's all your body weight.

Exercise to help nerve damage caused by Taxotere?

Question from Joan: What about exercise helping nerve damage caused by Taxotere as one of the chemicals used in chemotherapy (TAC)?
Answers - Julie Gralow, M.D. Peripheral neuropathy usually manifests as some numbness or tingling in the toes and is a side effect of chemotherapy agents such as Taxotere. I don't know any data that suggests that exercise can either prevent or treat the neuropathy associated with these drugs.

Help with motivation to lose weight?

Question from Denise: Hi. I'm 51 years old and I was already overweight (about 30 pounds) when diagnosed last July. I had a lumpectomy in August, followed by radiation. I'm finally feeling "myself" again, but despite knowing that being overweight can contribute to recurrence, I just can't seem to get motivated to increase my physical activity and lose weight. Please help me!
Answers - Miriam Nelson You need to put some mental energy into this one. Sit down with a pen and paper, and plan out your goals in terms of how much exercise you're willing to do each week. I would add something about eating well also.

You also need to think about a three-day food record. Write down the food you eat over three days: when, where, why, and what you eat. A lot of food gets eaten while driving in the car, at your desk, snacking, etc. that can contribute to weight gain.

With the exercise, think about what you need in order to be more compliant. Do you need a friend to exercise with? A class to go to? At some point, hopefully this mental work will help you with what I call the "switch" where all of a sudden it just clicks and you just realize it's time to become more active.

I'm a real advocate of exercise as a part of socialization. Dr. Gralow talked about it with Team Survivor Northwest. When you have a goal you're working for, it's so much easier to train for than to just go out and exercise for the heck of it. So finding a group where you can socialize and have fun, and where you have a goal can be exceptionally helpful.
Julie Gralow, M.D. I've just flipped open a copy of a book I'm a co-author of, Breast Fitness: An Optimal Exercise and Health Plan for Reducing Your Risk of Breast Cancer. I was pleased with some later chapters that dealt with this issue, and I'm reminding myself of the titles of the chapters—Develop a Health-Promoting Exercise Plan, Using Goals to Stay Motivated, and Overcoming Fitness Roadblocks. As part of this book, we created a chapter where members of Team Survivor Northwest talked about how they got involved and what they did for fitness. They were a real mix of women—some had been athletes, and some had never done focused exercise before. Different things worked for different people. Some of these women had to keep looking for what it was that would work in their lives and families.

There were successes right away, and some women had to work for quite a while to find how to achieve a healthy diet and physical activity. It really takes a lifestyle change and a commitment.

I find what keeps me motivated on these rainy winter nights in Seattle when I come home is my dog wanting to go for a run, and I come home to my husband who also needs to keep healthy. When we incorporate this healthy lifestyle into a family practice and commit to each other, that's what works best for us. Encouraging the whole family to engage in physical activity, or getting a close friend to help you can be helpful.
Judith Sachs It's easy to let yourself down for exercising, but not if you have a standing date with someone else.

Build arm strength after sentinel node biopsy?

Question from Sue: Having had a sentinel node biopsy, how do I reconcile the need/desire to build arm strength with the admonition to avoid lifting with the affected arm?
Answers - Julie Gralow, M.D. If just a sentinel node procedure has been done, the long term consequences with respect to risk of lymphedema, restricted arm motion and neuropathy are much, much less than for patients who have had an axillary lymph node dissection. It's not zero, but it's much less. So neither I nor a breast surgeon would recommend any restriction in arm activity post sentinel node biopsy, or for most women after an axillary dissection. Of course, post-op we will recommend common sense. But long-term, no limitations.

Routines for present good health and future?

Question from Reggie: What are your exercise routines? Are they designed for future good health, as well as feeling good and healthy now?
Answers - Miriam Nelson I feel very fortunate because I happen to love to exercise and I also get to do it for my work, in terms of that's what I study. I am a runner. I also do a lot of rock climbing, and depending on the seasons, I will bike or swim or ski. I tend to try to take advantage of the seasons, because I like the outdoors. I have three teenage children, so there was a long stretch when they were little that I barely hung onto my exercise routine. I finally told myself I didn't have to do it by myself, and the kids would grow up and I could get back into my routine. I love to think of exercise as being social, so I like to run with a team here at Tufts that runs a marathon every spring. I think of it as the future, but I also do it for now because it makes me feel good.
Julie Gralow, M.D. I also incorporate exercise into my life for the present and the future. I am a jogger, not a runner. I run at a slower pace, and I've never done a marathon, although I have done a couple of half marathons. With Team Survivor Northwest, I regularly do a women's triathlon with short distances. With Team Survivor, I had a chance to ride my bike from Seattle to Portland, which is 200 miles, and do a variety of other activities, like the dragon boating. On a daily basis, it's more the jogging and bike riding. I found I need to commit in order to get myself out there on these gray winter days. So now, my husband and I have planned a week-long biking trip in Croatia in May, so that's encouragement for me to get out on my bike so I'll be in good shape for this trip. I know that if I sign up for something and I've turned in my registration, that will help get me out there more in advance.
Judith Sachs I teach tai chi and exercise to senior citizens. My students, who are 75 and up, are my inspiration to keeping active. I do my tai chi every day. I do yoga and I jog. I bike in good weather. It is harder as I get older to feel that I can get past the aches and pains, and I just have to be very patient with myself.
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