How Breast Cancer Treatment Affects Your Ability to Exercise

Jamie DePolo: Hello, and welcome to the Breastcancer.org podcast. I’m your host, Jamie DePolo. Our topic today is breast cancer treatment and how would it affect or might affect a person’s ability to exercise. Our guest is Dr. Kathy Miller who is a professor of medicine at Indiana University. She has a special interest in new cancer treatments including biologically based therapies.

Dr. Miller’s career is a combination of both laboratory and clinical research on breast cancer, and she’s the author of more than 60 scientific papers, many of which focus on breast cancer biology and treatment. So, Dr. Miller, welcome to our podcast. We’re delighted to have you here.

Dr. Kathy Miller: Thank you, Jamie.

Jamie DePolo: Most organizations say that if a person is a regular exerciser before being diagnosed with breast cancer, then it’s usually okay for the person to continue to exercise during treatment. But what a lot of people have written into our site and asked is, how do you know what either a safe amount or a safe intensity level is, say, while you’re recovering from surgery or you’re going through chemo, or you’re getting radiation? Are there some guidelines that you would want to share with our listeners?

Dr. Kathy Miller: Well, let’s take each of those different treatments separately because the considerations are a little bit different.

Jamie DePolo: Sure.

Dr. Kathy Miller: So, the concerns about surgery are often about allowing time for the incision to heal, not putting undue stress on the incision, not pulling drains out before they’re ready. So those are really questions to ask your surgeon. And I would suggest that people talk about that immediate, first couple of weeks of surgical recovery with their surgeon before they have surgery.

Immediate postoperative time can be uncomfortable. They might be a little groggy. People are often only in the hospital overnight. Sometimes they might not even be in the hospital, and they may not see their surgeon again in an outpatient clinic for a week after the surgery. So asking those questions before surgery will just be much easier to know what to expect and what they can’t do.

Jamie DePolo: Okay.

Dr. Kathy Miller: During radiation, the issue is, really, is there rubbing or stress on skin that might be more sensitive due to radiation? Would significant perspiration in a radiation area be uncomfortable if there’s a little bit of skin irritation or redness? Those are also good things to talk about with your radiation oncologist as you’re getting started or as they’re doing the treatment planning, so that our patients can think about how they want to adjust their physical activity or their exercise routines to things that they would be able to keep doing or resume doing sooner.

During chemotherapy, those are really not the concerns. The concerns during chemotherapy are primarily that chemo does tend to make our patients more fatigued and more tired. So, they may need to decrease the frequency or the intensity or the duration of their exercise routines, but they’re going to do better and recover faster if they stay active than if they stop exercising entirely.

Jamie DePolo: Does that hold true for all the treatments -- surgery, radiation, chemo -- that if somebody continues to be active, as much as she is able to be, that recovery is better for all three?

Dr. Kathy Miller: I think it definitely does. If you took any healthy person and just put them to bed, put them on the couch for a few weeks or a few months and just didn’t let them do any exercise or any physical activity and now said, “Okay, you’re done. Back at it. Back to your fully active life,” you’re pretty pooped, and you discover that it’s very true, that muscles that you’re not using tend to go away. And what we want to avoid for our patients who’ve been active is adding the effects of deconditioning to the effects of treatment and then giving them farther to recover from when they’re finished with their therapy.

Jamie DePolo: Okay. That makes sense. Now, what about a person who hasn’t been very active, who perhaps is more on the couch-potato side of the scale, gets diagnosed and -- I’ve also heard this, women have talked to us about this, too -- so they decide to make some changes in their life. Like, “I’m going to be more active now. I’ve been diagnosed. I need to take better care of myself.”

What is a safe way for that kind of person to start to exercise? Are there certain types of exercise that might be better than others?

Dr. Kathy Miller: That’s unfortunately the majority of our patients who are either quite sedentary or they’re only minimally active. So this is really a common scenario. First, I think we need to manage expectations. Our patients are going to be getting treatments. Those treatments do have real physical effects, so it’s not a reasonable expectation to think, “I’m going to lose a bunch of the extra weight, and I’m going to end up at the end of my breast cancer treatment in the best shape of my life.”

But it is a time that we have patient’s attention and where they can start making changes that will lay the foundation for them to continue to be active and to increase their level of activity.

So, I have a couple specific pieces of advice. Activity in daily life is usually much more episodic and scattered throughout the day. It is unusual for most of us to be very sedentary and then go and have an hour of intensive exercise, and the rest of the time, we do nothing.

We’re often active in little spurts, and we can use that as a way to increase our activity. So, that may be simple things of taking the stairs at work instead of the elevator. Intentionally parking at the farthest parking space at the grocery store or the bank or your office parking lot, rather than circling to find the closest parking space. Taking an extra walk around the block on your way out to the car and on your way into the office. To gradually increase the amount of activity that you’re getting all throughout the day. I think especially for people who say, “I can walk for a couple of minutes and then I’m really pooped.” That’s fine. Start with a couple of minutes, but do that couple of minutes several times throughout the day.

Jamie DePolo: Okay.

Dr. Kathy Miller: The other is that most of my really exercise-physiology colleagues would suggest that people starting an exercise routine for the first time start with something they can do that doesn’t have you out of breath, doesn’t have you sore, you can still be able to talk to a partner. That’s your starting point. And think about increasing that by about 10% a week.

If you think about it, Jamie, that means if you take a 10-minute walk, week two, you take an 11-minute walk. That’s a really small increase, and that’s exactly the point. It’s a small enough increase that you’re not going to get injured, you’re not going to suddenly hit the wall and think, “I just can’t do this, this is not for me.” But if you keep consistently increasing, you will get there, and you will get there in a way that is going to be safe.

Jamie DePolo: Just to clarify, I want to check, when you said increase by about 10%, you meant duration, not necessarily intensity.

Dr. Kathy Miller: It can be either.

Jamie DePolo: Okay.

Dr. Kathy Miller: It can be entirely duration. It can be an increase in intensity. Intensity is easy to monitor if you use a treadmill or a bike that tells you about the intensity. It can be a little bit harder to really gauge intensity when you’re walking or swimming or doing things on your own. So, it can be either of those. But I think that gives our patients a guideline.

Years ago when I first started exercising, I lived out in the country, and I would walk along the country roads that have telephone poles. And to keep track of what I was doing and know that I was gradually increasing, I would count the telephone poles. And to increase the intensity, I would jog from one pole to another and then walk for five poles. And the next week, I’d jog for two poles-worth and then walk for five poles. So, there are ways of using the environment to keep track and keep yourself going.

But the key is a small but consistent increase that will keep you moving forward, not such big jumps that you end up so short of breath that it’s uncomfortable and might be unsafe for some of our patients, and not so much that you end up sore and not able to continue.

Jamie DePolo: Okay. That sounds like very good advice. Now, I want to talk a little bit about stamina. When people have told us as well, “You know, I used to be able to swim for a half an hour before I had treatment, and now it seems like I can only go for 10 minutes and I’m very tired.”

Is that somewhat of a permanent change, or does the stamina ever come all the way back, or do people just have to accept, like, “Okay, I’m not going to be able to do exactly what I could do before?”

Dr. Kathy Miller: I think it does come back, but it takes work. When we looked recently at the physical impacts of many of our therapies, you could lump those physical impacts into a couple of different groups. Some of our treatments may lead to some anemia, which decreases the ability of the blood to carry oxygen to the muscles, and that will definitely impact stamina, particularly for more endurance things -- walking for longer durations or swimming for a longer duration.

But we also saw loss of lean muscle mass with a compensatory increase in the amount of fat tissue. So, our patients’ weights didn’t change much, or if they changed, they tended to go up. But when we looked at their body composition, they were losing lean muscle mass. So, part of that loss of stamina is that you have actually lost muscle. And that will take some time for the anemia to recover, for the muscle to rebuild, but it will.

Jamie DePolo: Is the muscle loss strictly from inactivity or is there something in the treatment that perhaps contributes to that?

Dr. Kathy Miller: I don’t think we know, Jamie. Many of our patients in this study were quite sedentary when they started treatment. We had them use pedometers regularly so we did see that they moved less, although many of our patients were so sedentary, it was actually hard for them to move less than the little bits that they were already moving. So I don’t think we could really separate how much of the muscle loss is just deconditioning in activity and how much might be a direct effect of the therapy.

Jamie DePolo: Okay. So, I guess one sort of suggestion to people who are going through treatment and who maybe were fairly accomplished athletes before is to not get discouraged if this stamina is down after treatment.

Dr. Kathy Miller: Oh, absolutely not. The treatment has a real effect. That is true for chemotherapy and for the antiestrogen therapy. We were surprised to see that the effects of antiestrogen therapy were not that different than the effects of chemotherapy. So, these effects are quite real, and they tend to be the most profound shortly after treatment has finished, but they do tend to get better. But it will take some time.

So, I think another guide to help patients adjust their expectations to avoid them from getting frustrated: If you assume that every day during the course of your treatment it will take you a day after you are finished with therapy to fully recover. If you imagine someone who had surgery and then 4 months of chemotherapy and 6 weeks of radiation, that’s going to take them in the range of 6 to 9 months after they finished therapy to fully recover.

It is not that they’re slowly recovering throughout that entire period, but it gives people, I think, a realistic expectation so that when they don’t feel completely like their pre-breast cancer, pretreatment self a month after treatment has ended, they’re not discouraged and assuming that this is as good as I will ever be.

Jamie DePolo: And you brought up hormonal therapy, which is interesting, because that can go on for 5 or 10 years. Now, does that mean that, say, a woman who’s taking hormonal therapy for 10 years, does she then have 10 years of recovery from that?

Dr. Kathy Miller: I don’t think so. Our observational study just followed patients over the first year of treatment. We expected to see significant changes with chemotherapy. What we were hoping is that we would see some recovery between a 6-month assessment and an assessment a year after diagnosis. In most of our patients, we really did not see that spontaneous recovery, but these were predominantly sedentary women to start with. We were surprised that at 6 months, the impact of hormone therapy was almost as big as the impact of chemotherapy. And that also looked pretty similar at 12 months.

So, we’re now looking at interventions to try to help sedentary patients start to be more active so that they can recover better and more fully.

Jamie DePolo: Okay. Okay. Are there certain forms of exercise that you would suggest are perhaps better or offer more benefits for people who are in treatment or who are recovering from treatment?

Dr. Kathy Miller: I don’t think we can say there is one form of exercise that is better than another. There have been a few studies that have tried to separate and look at strength training or resistance training versus aerobic exercise. They found benefits for both, and I think it’s hard to say one is better than the other. Since so many of my patients are fairly sedentary, my answer is simple: I will take whatever exercise you like and that you are willing to do and that you’re going to continue to do.

And that is, for most of us, going to be a combination of different things, because if it’s only one form of exercise, most of us get a little bored. And as we start to get bored, we start not doing it. So, that may be predominantly gardening and walking outside during the summertime, but when I hear that for patients during the summer, I start talking to them about, “What’s your plan going to be for keeping at that level of activity during the winter when you’re not gardening?”

For my patients who like skiing, who are more active during the winter, what are they going to do during the summer? It might be dancing. It may be things that they’re doing with grandchildren or with the husband that gives them social interaction as well.

I think for our patients who start out sedentary, I’m just much less picky about what they’re doing. If they start doing something and start to notice how much better they feel, we can then work on increasing, saying, “It’s great that you’re now doing all of this aerobic exercise, let’s talk about balance training and strength training.” If they’re starting out with strength training, we may be able to bring in some additional aerobic exercise once they’ve gotten started.

Jamie DePolo: Okay. And I’m curious, too, is there a certain length of time or an average length of time where a person who, say, has been fairly sedentary starts walking daily, when she would see some results, whether it’s better stamina, just feeling better, losing weight, losing inches, or is that more individual?

Dr. Kathy Miller: It’s a bit more individual, although most of my patients who have started moving start to notice that they feel better. That they feel different. They have more sense of energy within the first few weeks. It takes surprising little if you’re starting from a very sedentary place to start to notice that you feel better.

Losing pounds and losing inches is going to take longer, and for most of us, just adding exercise is not very successful as a weight-loss strategy. And that’s a combination of two things. We tend to overestimate the amount of calories we’re using and the exercise that we do. And it’s very easy to add an extra hundred calories a day to completely offset the 100 extra calories that you were using in your exercise program.

So, these are not people who are intentionally saying, “Well, I took a 10-minute walk today so I can have this big piece of chocolate cake and they’ll offset.” But it’s pretty easy to add an extra 100 calories. Our bodies don’t really like having a calorie deficit, so just exercise is not very good as a weight-loss strategy. It is a wonderful adjunct to making healthy dietary changes and decreasing portion sizes and restricting calories to help you lose weight. But if the only change you’re making is exercise, you probably shouldn’t expect weight loss, but you should notice greater energy, greater stamina, less daytime sleepiness, and that you just feel better. You feel able to do more in your day.

Jamie DePolo: Okay. And one last question before we go. You mentioned weight training earlier, and I know a big concern for many women after surgery is lymphedema. And in your research, do you avoid certain types of exercise because of lymphedema risk? Are there exercises that you would recommend, or certain types of exercise that you’d recommend for a woman who’s been diagnosed with lymphedema?

Dr. Kathy Miller: This is another area that has not been very well studied. And the most recent studies have really challenged what our patients have always been told. For years, they’ve been told to avoid heavy lifting, avoid resistance exercises because that may trigger lymphedema.

But there have been some recent studies that actually looked at weightlifting. Initially small weights, in the 3- to 5-pound range in women who have lymphedema. And it didn’t make their lymphedema worse, it made their lymphedema better. In some ways, that makes sense. Part of what moves the fluid from the limbs back into the circulation is muscle contraction. So if you’re using those limbs more, that may help clear some of that lymphedema fluid.

I think this is a case for balance and talking, for a patient to have lymphedema, with their physical therapist. What I suggest my patients do is start slowly. If they start noticing their arm having that achy, heavy feeling, that’s their arm telling them that it’s starting to struggle, and the pressures are increasing and they’ve done enough for now. They need to stop and let their arm rest. But at this idea that our patients can’t ever get back to full activity, can’t ever participate in weightlifting or bowling or those things again, is just simply not true.

Jamie DePolo: Okay. Okay. Great. Thank you very much, Dr. Miller. We really appreciate your time and being a guest here. And hopefully as you do some more research, we can have you back and do a future podcast as a follow-up.

Dr. Kathy Miller: My pleasure, Jamie. Thank you.