One Step at a Time: Starting Exercise After a Breast Cancer Diagnosis

Dr. Marisa Weiss: We're so grateful to have all of you with us today. And we know that starting to exercise can feel overwhelming, especially during or after a breast cancer treatment because your body's been through so much, you just don't know what it can handle. When you think about your energy level being low or unpredictable, side effects can linger. You've got a little pain here or a little ouch when you go like this. And you probably have a lot of other priorities pulling you in different directions. I've been taking care of women for 30 years and there's never just one thing going on in someone's life. There's so much of everything. And we also know that when you go through all this, if you do a few days without being active, your body gets de-conditioned. But the fact that you're here now empowering yourself with knowledge means you're already on the right path. And truly, exercise can change your life at any age. It's never too late to get started, and we're so glad to have you today.

In this webinar, you'll hear about the research that has convinced doctors and other healthcare professionals that exercise is medicine. And as a breast cancer survivor myself, I have lived it and I want you to experience the benefit of movement too. For anyone, and especially after a diagnosis, you'll find that exercise is no longer optional. It's mandatory if you want to live a good and healthy life. This is your time to learn, ask questions, explore what working out regularly can look like for you wherever you are in or past your treatment for breast cancer.

First, I want to take a moment to acknowledge our generous sponsor, AstraZeneca. Thank you for making this event possible. And we're lucky to be joined by two brilliant speakers. They have devoted their careers to understanding everything there is to know about the connection between exercise and breast cancer. Sami Mansfield is an exercise oncology and lifestyle medicine consultant and the founder of Cancer Wellness for Life. She empowers cancer patients, survivors, and clinicians through her innovative evidence-based programs. Sami is a contributing author to groundbreaking guidelines, including the American Society of Clinical Oncology Guidelines on Exercise, Nutrition, and Weight Management, and is currently the chair of the Cancer Member Interest Group for the American College of Lifestyle Medicine.

And Dr. Melanie Potiaumpai is an assistant professor for the Division of Hematology and Oncology at the University of Pittsburgh School of Medicine and the co-director of the university's distinguished Moving Through Cancer Program. She's also a member of the American College of Sports Medicine. Her research focuses on the link between exercise and cancer prevention, as well as side effect management and survivorship to help people improve their quality of life and their longevity. It's never too early or never too late to start moving and exercising.

To set the stage for our conversation, let's touch on some of the science-backed benefits of exercise that we'll be discussing. Exercise can keep you strong, get and keep you strong. It can reduce the risk of developing breast cancer or its recurrence. It can ease side effects like fatigue, pain, nausea, joint and muscle discomfort. It can help reduce the risk of lymphedema, a swollen arm that you might get on the same side as your treatment, and lessen symptoms. It can help keep your bones strong, keep your heart and blood vessels healthy, lessen anxiety and boost your mood, improving how you think, remember things, and reduce your risk of dementia. Exercise can help with weight loss and weight management, and it's extra important to exercise, especially if you're trying to lose weight. But if you're on one of those medicines, the GLP-1s, you lose weight, including muscle and you want to keep that going.

But even if you don't lose weight and you're not interested in losing weight, exercise is still really important for all the benefits we cited above. It can help get you a good night's sleep. It can increase your mobility and your flexibility, your ability to do what you need to do, want to do, and be independent, right? Keep moving on your own, do what you need to do when you want to do it, and build your self-esteem and confidence. You know that extra pep in your step when you've been exercising regularly. But knowing the benefits doesn't automatically make it easy, and that's why we're all here today, to help you find ways to move that feels safe, doable, and right for your individual situation.

Before we get into the panel discussion, I want to introduce you to an amazing member of the Breastcancer.org community who has some words of encouragement for you. Here's Toni.

Toni: I was diagnosed with stage II - III invasive ductal carcinoma. I can't even articulate how deep the sadness, anger, anxiety was for me being diagnosed. I had to choose a path, and that path was, "I'm going to fight this cancer with all my might. Whatever it takes, I am going to fight to make sure that I can do the best possible thing to increase my chances of continuing to live." 

The physical and emotional effects of diet and exercises really started during chemo, just taking a few steps in my home to eventually, as I felt better, a few steps out of the house and back. So those initial baby steps of walking actually made me feel better. Did it make me feel so good that I didn't have my symptoms? No, but it actually made me feel better.

My walking regime has not only improved my health by having me lose a lot of weight — I lost up to 60 pounds in a gradual process — but I really look forward to it every single time. 

For those of you who think that you cannot exercise or get moving, I was that person as well. And I will tell you and encourage you that once you have breast cancer, I and many thousands of other women out there are going to root for you. Just know that we're there rooting for you and you can do this. I did it myself. Started small and now today, just really go out there and make sure that I can get those 15 to 20,000 steps that I try to attain. So you can do this. You just have to have the mindset to know and the inner strength to know that you're doing this for yourself so that you can be here living longer.

Dr. Marisa Weiss: Thank you so much, Toni, for sharing your story and for inspiring all of us. I've certainly been there and your words encourage me because we have to keep going. It's exercise every day, even though I'm 15 years out and it took me a lot to get moving and grooving again and learn how to exercise. Your words of encouragement are relevant even today years later.

Now it's my pleasure to welcome Sami Mansfield and Dr. Melanie Potiaumpai. Sami, let's start with types of exercise. Can you explain the difference between aerobic exercise and strength and resistance training, and why both matter for people with breast cancer? And what should people know about yoga and stretching?

Sami Mansfield: Thank you so much for this fantastic question because I really think that the definitions of these are really important because what is exercise and why does it matter, which I think is why we want to define these. So if I think about aerobic exercise, aerobic exercise is movement that predominantly uses large muscle groups in kind of a rhythmic fashion. This doesn't mean we have to be dancing, but think about activities like walking, biking, and swimming. You kind of get into that range of motion throughout your full body. You'll feel an increase of heart rate, you'll feel your lungs working because that is really the primary role of this type of exercise.

Resistance training exercise, also known as strength training exercise, is movements that create load or tension on muscle. Not necessarily that we have to lift weights, they could be body weight, but we're creating stimulation in the muscle with the objective of making our muscles stronger, more endurance, more power, thinking about maybe getting off of the toilet or going up a flight of stairs or even doing something like an exercise like a squat or whatever that may be.

For Pilates, yoga, stretching, I know I'm adding Pilates in there because people ask, I know you didn't ask about that one, but a lot of these are really designed at base to be kind of more recovery and range of motion. Now, I can tell people already might say yoga feels like strength training or balance, and it is, but in general, a lot of those types of modalities are really focused on lengthening muscle, creating stability.

So the high level question is, how are these important for individuals related to breast cancer? First and foremost, all of them are important. However, when we're really thinking about getting started, you may not be able to do all of them at once. So I usually tell people we should choose maybe a priority based upon our goal. 

So if you are noticing you're feeling weak, you're feeling like you don't have enough power, then maybe strength training is your starting place. If you're feeling like walking has been more difficult, maybe getting into aerobic might be your best starting point, even if you're doing a march from a chair. Maybe you're feeling tight, you're feeling those aches and pains, maybe it's going to be those recovery type exercises. But really, honestly, all are really good. 

I do love your comment, Dr. Weiss, about losing weight and body composition. I know we're not going to go into that at depth, but I do say that if you want to lose weight and improve your body composition, do not forget strengthening and resistance even if you are not on a GLP-1 because we need muscle mass, especially as women related to breast cancer if you've also gone through menopause. So all important, but by priorities.

Dr. Marisa Weiss: Right, absolutely. And that's what all this protein craze is about, is to make sure you've got the nutrients you need to keep those muscles happy and working. And we have a webinar coming up on nutrition and we have content on Breastcancer.org, but it's so important to keep you strong through the transitions in your life, which includes going through breast cancer, includes going through menopause, it includes going through treatment. 

Dr. Potiaumpai, what are the current recommendations for weekly exercise, both in terms of time and intensity, and how flexible are those guidelines? If one week is crazy and you're traveling and the next week you're home, what wiggle room is in there and what do we plan for?

Dr. Melanie Potiaumpai: Sure. So the American College of Sports Medicine did this huge collection of the evidence and research to see how much and what type of exercise is needed to help play a role in health and different outcomes. So we know that for cancer survivors, and we use these guidelines for also patients who are receiving treatment, we recommend 150 minutes of aerobic exercise per week at a moderate intensity. 

So we have low, moderate, and vigorous intensity. So when we say moderate intensity aerobic exercise, you should be able to exercise and hold a conversation without getting too much out of breath. If you feel like you're exercising and you can't speak or you're stuttering or trying to catch your breath, that means you're exercising at a more vigorous intensity. So for the 150 minutes, which can be spread across the seven days of the week, you want to stay at moderate intensity. If you are an adrenaline junkie and you want to do a vigorous activity, then we recommend 75 minutes rather than 150. So 150 for moderate and then 75 for vigorous.

And then we like to sprinkle in, on the days that you're not doing aerobic exercise, at least two days a week of strength training per week. And we try to recommend exercises that target major muscle groups over the total body, both upper, the trunk, and lower body. And resistance training doesn't have essentially a time limit on it, but we recommend around 30 to 45 minutes. And that includes breaks in between each exercise. You don't have to consecutively complete all of your strength exercises. And you want to try to stagger your aerobic and strength training days to give yourself some rest in between. Rest days are extremely important to be able to fuel your exercise days and make sure they are effective and efficient.

Dr. Marisa Weiss: Yeah, absolutely.

Dr. Melanie Potiaumpai: Yeah. And so in terms of flexibility, these guidelines are extremely flexible. So if you only have a certain amount of time or a certain amount of energy per day, do what you can and know that one week is going to be different than the next week. So whatever you can to try to meet those guidelines, I think are extremely important.

Dr. Marisa Weiss: Yeah. I have this band here and I know I've had a lot of surgery in the front, but if I go like that towards the back, I'm working my back and that's sort of the resistance. I have this around, it's pretty convenient.

Dr. Melanie Potiaumpai: Yeah.

Dr. Marisa Weiss: And on the weeks that... I live on the 19th floor of this apartment building and I always go down the stairs and I go down with a little bit of a force in terms for bone health, to a little bit of a jolt, but I'm not jumping down the stairs. And then I'll walk up the stairs, 19 flights, which I consider not just vigorous, but super vigorous. So I give myself extra credit for that because I'm out of breath and I can't do anything. I can't talk or sing or anything else while I'm doing that. And that's, I try to mix it up.

And I invite you all to get resourceful and figure out how to integrate physical activity, not just exercise per se. And one of the things that gets people stuck is that once you start exercising, you might be less likely to do the walking to the store or walking up the stairs and down the stairs. No, no, no, no, no, no. You got to keep that rhythm and the beat in your life of being physically active and you want to do the exercise and resistance training on top of that.

And while I got you, Dr. Potiaumpai, there's that really important study of the CHALLENGE Trial, showing the value of exercise for people with stage II and III colon cancer and how it’ll help people live longer. And what does that research do to... How does that help people who've had breast cancer? What insights and lessons learned can we apply to us?

Dr. Melanie Potiaumpai: Sure. So what we know is that the relationship between the amount of physical activity, so how much physical activity we're doing, and exercise is inverse to breast cancer-specific mortality or death from either breast cancer or all cause mortality. So people-

Dr. Marisa Weiss: And when you mean inverse, you mean the more you do it, the lower your risk?

Dr. Melanie Potiaumpai: Right. So people who engage or who do more amounts of physical activity and exercise show a lower risk of death, either cancer related or not cancer related. And that's exercise that we do consistently. So we have a routine, not those January resolutioners where we have a new year resolution, we do exercise on a daily basis or some type of physical activity on a daily basis. If we do that month after month, year after year, that contributes to the lower risk of cancer and non-cancer-related deaths.

Dr. Marisa Weiss: Right, right. Absolutely. When you get started and you integrate exercise into the rhythm and the ritual and the routine of your every day, then your body's going to ask you to do it. I don't know if anybody who's listening has had a dog that you've walked. As soon as that dog sees you going towards the door, their dog is ready to go. That dog wants to go out and run around. Your body's the same way. Once you get started, it's easier to get into the rhythm of it. And for anything in life, what you practice grows stronger. So the more that you practice exercise and figure out, how am I picking up this weight so I can work this muscle, not that muscle, not hit myself on the head when I go back with that? That's all practice with someone who knows what they're doing.

And then the better you get at it, the more fun you'll have, and the more fun you have, then the more people around you in your life are going to be watching you and being inspired by you. And then that might inspire you to take on other steps. So people who are exercising regularly tend to do other things that are healthy in their lives like eating well.

And to that, I was just going to ask Sami, we know that exercise can help with managing some of the difficult and long-lasting side effects of breast cancer treatment. Can you say something about how exercise can help with the fatigue, the joint and muscle discomfort, nausea, sleeping issues? What's your line on that?

Sami Mansfield: Well, I definitely think, and we know from research, exercise is just largely beneficial. I do really want to say for our audience, if you are experiencing side effects, you may not be able to do the same type of exercise. If you're having a lot of nausea, doing vigorous intensity is probably not my first recommendation. But overall, anything that you can do, even if it's lying in bed and lifting one knee into your chest at a time, will help largely every side effect related to cancer treatments, both physically, emotionally, or treatment side effects.

When we think about things like fatigue, number one across the board, exercise improves fatigue. I know that seems a little contraindicated, but it really does. You'll get a little bit of boost of energy, but you're building up the capacity of your body. You're building your strength, you're building your endurance, you're building that oxygen in your brain and your mood. So certainly think about that piece.

I know we're going to talk a little bit more about thinking about joints, but I want to remind everybody that one of the reasons that we see a lot of joint pain in particularly the conversations of breast cancer is definitely around common medications such as AIs or other hormone blockers, but largely it's because we've lost a lot of that strength in large muscles such as our legs. So we lose muscle in our thighs, and now my knees have to take the load of my body when I get off the toilet or I go upstairs. So I want you to be thoughtful about your body and what you're experiencing.

I think it's important to consider that doing something is better than nothing, but listen to how you feel and try what feels right that day. Maybe it's just one little flight of stairs. Maybe we don't have 19 flights, although I highly admire 19 flights. Maybe it's walking up to your staircase and going up and down two or three stairs and then sitting back down. But I really don't want anybody listening to feel like exercise is going to make their side effects worse, but listen to your body, do something even if it's from a chair, but like the band or weights, try something that feels good to you.

Dr. Marisa Weiss: Right, right. And this is not a competition. Even though a lot of times you did exercise in a competitive setting maybe when you were younger in school, this is not competition. This is just a part of your daily habit, and you can't improve on a habit if you don't have that habit in place. So getting started is the key thing. And we do have a lot of research that shows that going from nothing to something is where you're actually going to capture the greatest benefit.

And also what Sami was saying about AI, AI stands for an aromatase inhibitor like anastrozole/Arimidex or Femara/letrozole or exemestane/Aromasin, those are the names of those medicines, that can, when you start taking them and... Any transition in your life, including starting a medicine that can affect bones, can steal away some of the density, the strength of the bones. And so that's where our muscles really help us out by trying to keep those muscles strong because the muscles talk to the bones and the bones get stronger as a result. So it's all very important.

Let me ask Dr. Potiaumpai about other medicines that can potentially be an issue with exercise. For example, not commonly, but sometimes the CDK4/6 inhibitors like Ibrance, Verzenio, ribociclib can cause some heart issues. And then there's some other medicines like the Faslodex or the new giredestrant may cause a change in your heart rhythm. So is there anything that patients should ask their doctor about or talk to their doctor before they start exercise if they're concerned about the impact of the medicine on their heart health?

Dr. Melanie Potiaumpai: Yeah, so with exercise, regardless if it's cancer or non-cancer-related, we always advise that you should always consult with your physician prior to starting a new exercise routine just to make sure everything is in check. 

So specifically for CDK4/6 inhibitors, there is some evidence to show that they can cause some cardiovascular issues. So what we know generally is that exercise is beneficial for cardiovascular health, but the issues that are caused by these CDK4/6 inhibitors are not the same that are targeted by exercise. So what I mean by that, it could cause things such as arrhythmias, heart failures, thromboembolic events, so things that exercise can't necessarily fix or have been shown to fix in the research. So it's really important to go and see your physician prior to make sure that you don't have any existing conditions or risks that could be exacerbated by exercise.

And that's the same with oral SERDs as well, the selective estrogen receptors. Again, cardiovascular and aerobic exercise is beneficial, but again, you don't know if you have something that might be preexisting that might set off those cardiovascular events. 

And if you are landmarked and you are told that you can do exercise, what you want to make sure is that you start off very low in terms of intensity and the amount of time that you're doing exercise and eventually build your way up to either your goal exercise time or the guidelines to make sure that there's no worsening of any side effects that you might be feeling or new side effects that might come on from the exercise. And then if you are feeling some side effect that is a little bit abnormal, you should absolutely go see your physician again to make sure that the exercise that you are doing is not triggering some type of event.

Dr. Marisa Weiss: Yeah. After surgery, these days, the incisions could be really small, like in the armpit, they can be really small, but when the surgeon was in there, they were in and around the corner. And then in the breast area there, even though the incisions looked like they're well-healed, on the inside, there was a lot of changes going on. Tissue was removed, and then you were sewn up again. Surgery is an injury, you get cut, but then they sew you back up again, and you want to give your body a chance to heal from those procedures and not aggravate it too much or stretch it out or yank on it by doing exercise.

And there's some exercise that's different from other exercise. I take care of a golfer who's really aggressive with her swing and it's like, that may not be the right exercise for you. The good news though is that your biggest muscles are waist-down, which are usually separate from the area where you've had treatment, unless you had a reconstruction where they borrowed tissue from the lower belly and brought it up to rebuild the breast tissue, in which case you got to be careful about that incision's ability to heal as well as the incisions up in the chest area.

So it's good to have a dialogue with your doctor, and that's one reason why you go back to see your doctor for your post-op checks or for your medicine checks and all that, is to ask those questions. 

Sami, I know that a lot of people are on those aromatase inhibitors, which can, as we were discussing, can affect your bone health, the density of your bones, how strong they are. Can you tell us a little bit about how exercise protects bone density and why it's so important for someone's overall health to keep your bone strong?

Sami Mansfield: Yeah, absolutely. I mean, it's such an important question and losing bone, having that osteoporosis or just even osteopenia, is kind of a process of aging. So as we're all aging along here, we're losing bone, and then of course these medications can exacerbate it. So first and foremost, we want to think about reducing your sedentary time, because as we've heard, adding load to your body, particularly adding load that might be vigorous or have a little bit of intensity, it doesn't have to be jumping, but even thinking about going down the stairs, as we heard from Dr. Weiss, and thinking about that type of activity makes a big difference.

But from a practical standpoint, when we think about exercise, there are two key pieces. If you want to think about the aerobic piece, walking is good, but your walking needs to be vigorous. So if you're walking your dog and your dog is stopping to sniff every few minutes such as mine, that may not be something where you can get that vigorous intensity. Sometimes I might recommend people look at a weighted vest, or even as simple as loading up a backpack or a fanny pack with something that can create a little bit of extra tension on your bone to create more vigor.

Or really thinking about resistance training, especially when you can do functional movements, such as I will demonstrate here in a little while, where you're doing multi-joint tension on not just your joints, but you're really tensing on the muscles that are pulling on the bone. So it's really helping to build and support new bone cells. And also the more muscle you have over time means you're having more tension on your bone. So having that more muscle is only going to help your bone density over time.

I do want to add a caveat people ask me of, do we have a conversation over the bone density medications my oncologist has recommended over exercise? And I will tell you, it is not an equal. So if your physician oncologist has recommended those bone-building drugs, I do want to warn people that exercise cannot replace the benefit of those medications. Because I hear that a lot, "I don't want to do those. I just want to exercise." But you should exercise and it is a really important addition to what your clinician would recommend. And Dr. Weiss, I definitely want you to add if I missed any commentary on that particular topic.

Dr. Marisa Weiss: Well, any healthy habit that you have in your life that becomes a rhythm and a routine keeps you on a healthy path. And the people who are more likely to exercise and get good at it and feel confident about it and get in the rhythm of it are more likely to do other healthy things like prepare your own food and not have as much salt in your diet and have more flexibility and less of a risk to fall. But we all need all the little... It's good when you have someone to do it with, so get a buddy. What I like to do, for example, is I call my sisters because I'm from a big family, we talk to each other. We'll both get on our phone and head out the door and doing exercise outside, especially in the morning, the light is a signal to get your body rocking and rolling.

I get up really early because I have to be at the hospital every morning really early. So I actually have an exercise bike and I go on for 10 minutes a day. And you might think 10 minutes a day, that's not very much. Actually, we have research that says that even 7 to 10 minutes a day is enough to keep your metabolism going. It's a good way to remind my body that the day has begun, it's time to rock it out because I have a long day and I'm a terrible sleeper. And so part of my sleep hygiene and my cognitive behavioral therapy for sleep, my own little structure that I try to put in place, is to really get up at the same time and also to mark that waking up thing with something else than just lights up and get out of the bed and get dressed in the shower kind of thing. The exercise goes a long way.

And then even standing up, like working in a standing up position, even two hours a day can make a difference in being healthy overall. So I'm a very practical person and one day is different from another. And I just know that, and I'll say it again and again, that exercise is not optional. It becomes mandatory if you want to live that long, healthy life where you can do what you want to do when you want to do it and remain as independent as possible.

Now I'm going to ask Dr. Potiaumpai about lymphedema. When the plumbing of the arm or the breast gets altered by your treatment and you might have a risk of swelling of the arm or the breast area. And it's a major concern for a lot of people in our audience. And I want to ask you, the guidance around exercise and lymphedema, what we've learned about how they interact and what you can do to have exercise help with your lymphedema, and how do you prepare for all that? What do people need to know today?

Dr. Melanie Potiaumpai: Sure. So what we know is that the old school thought was that exercise was a thing that we needed to avoid if you were at risk for lymphedema or if you had lymphedema and that weight training would make lymphedema worse. From the research that has been gone on for the past two decades, we know that's quite the opposite. So we know that for women with lymphedema, you should be doing slow progressive strength training and that does not worsen lymphedema symptoms and actually helps to improve your muscle mass, your strength, and your physical function. And that there's actually no upper limit on the amount of weight that you can lift. And so for women at risk for lymphedema, we know that slow progressive strength training actually reduces your risk of developing lymphedema in the future compared to women who do not actually do any strength training at all.

And so when I say slow progressive strength training, that means starting off with a slow weight and doing a low amount of reps. Give yourself frequent breaks in between your exercises. And then taking inventory of if you're feeling any type of symptoms that might be coming on from the weight that you're doing. Once you start doing that weight more consistently and you notice that there's no changes in your symptomology or a flare-up of your lymphedema, then that way you can start adding a little bit more weight, and then you do that weight a little bit over more over time consistently. And once you realize that there is no flare-up or symptoms or side effects, then you increase the weight again and again and again.

But it's just really about taking care of that. There is no competition to get to the next weight. No one's recording how much weight that you're doing. So it's very important that you take the time to make sure you're doing the weight consistently and make sure that there are no flare-ups. And if there are, there's no harm in going back down in weight and then doing that weight for a little bit more and then moving up.

And then the last thing about exercise with lymphedema or at risk for lymphedema is that we strongly encourage wearing a properly fitted compression garment while you're doing exercise. So I heard from massage therapists specializing in lymphedema that if you wear the compression garment and you're doing resistance training, that garment actually helps to push the fluid out towards drainage while you're doing exercise because it provides a very rigid point for the fluid to hit with the repetition of your muscle moving. So because of that garment, it can help increase drainage compared to if you don't wear it at all.

Dr. Marisa Weiss: Absolutely. After I went through all my treatment, just like you said, I started low and I worked up slow. And I have big arms so I started with just my arms alone, which was already a challenge just to get them up here and get them back and to the side and move and groove. Then I added a little this, a little of that, like one pound, two pounds, three pounds. And I have these here five pound weights and it might be nothing to somebody else, but to me, I'm proud of the fact that I actually got to five pounds and to go back like this without hitting my head to do the triceps was an achievement. And I just keep going at that level. I don't push myself too hard there, but I might push myself harder for muscle groups that are bigger, that are away from where I had all my surgery and treatment.

But again, as you said, everybody's body is different. And you want to talk to your doctor — and it may be your surgeon, your plastic surgeon, your medical oncologist, your radiation oncologist — about what form of exercise. I know in the treatment of women with breast cancer with radiation, we don't like to have a lot of skin rubbing against skin because there is friction, moisture, pressure, heat. So we always tell people to keep the skin folds open, like keep your arm out open in the rested position like this.

So if you're going to do exercise here, you want it to be out to the side a little bit, not this, because then you're in the armpit, the skin can get upset and maybe get irritated and you might get a blister. And so also when you're exercising, you might need a bra to give you the support that you need. So you want to talk to your doctor about what garments, or your exercise person, what garments do you need that are going to be safe to wear, give you the support you need, but without rubbing in the wrong places.

Dr. Potiaumpai, while I have you, can you talk to me about the powerful effect that exercise has on our mental health? This is really an important thing. We have a lot of studies that show how valuable exercise is on your mood, how you feel, and then more emerging about your cognitive function and all of that.

Dr. Melanie Potiaumpai: Sure. So we tend to forget that exercise does have that mental health benefit because we feel it mostly, the muscles burning, our heart beating, our breathing increasing. But over time, if you do consistent exercise that you enjoy — which I think is another part of the mental health aspect is that pick an exercise that you actually like so that you consistently do it — it has been shown to improve your quality of life, how you perceive daily life. It reduces anxiety, especially anxiety associated with either getting treatment or in between treatments, especially if you're waiting for scans or results, and it reduces depressive symptoms as well.

In its simplest form, exercise provides a mental distraction from day-to-day responsibilities and anxieties. It can be a stress reducer. It can help improve your self-esteem, especially if you've reached a certain goal and now you can create a new goal for yourself for something that you thought you couldn't do. It helps you feel confident, especially if you're feeling low about something else. You can feel good about exercise that you're doing for yourself. And it also provides the opportunity for social interaction or just to be in a different setting. You could be in the staircase going 19 floors up and that's different from being sitting in the chair either at the hospital or at home.

And then depending on the type of exercise, like Sami talked about before, different types of exercise provide different types of stimulation. So some exercise can be good as a form of meditation or mindfulness or reflection, helping you to evaluate your current state of mental well-being and then provides you with a chance to reset depending on what's going on in your life. And it can also be a form of physical outlet. Sometimes you need to channel any negative thoughts or feelings or aggressions, and exercise is a great outlet for that. And while there are other ways to do it, what's not a great way besides exercise?

Dr. Marisa Weiss: Absolutely. I do find that walking is meditative because anytime you're doing something like a rhythm and repeat, people pray and exercise, people think and exercise, people turn their mind off and just meditate and exercise, all good. And I have to say that when I was diagnosed, my children were adolescents. And I'm just being totally honest, there were days I wanted to kill them and I was so pissed and I wanted to... really wanted to get either... They knew what I was going through. They totally ignored it. Still the clothes on the floor, still wanting to know what's for dinner tonight kind of thing.

And if I hadn't exercised, I believe it, I would've been in jail because I would've done something to them. But I managed my energy and my negativity about it. And breast cancer really puts you out and it can make you feel angry, frustrated, betrayed by your body. So whenever you can find some strength in your body and you have time to yourself to recalculate and get grounded, it's a good thing. It's a good thing.

Okay. Sami, you help people get a plan and stick to it. And what are the practical things that you suggest for people who have really tight time in their schedule? And is it really effective to do the shorter, more vigorous exercise if you don't have the time to do that 150 minutes of moderate exercise? What are your tips, practical tips with that?

Sami Mansfield: Absolutely. And actually, I don't think you have to go short and vigorous. You could just do short. I think the bottom line is even if you have a minute or 30 seconds, and I'll give you an example, I patiently make my coffee on the stove top every morning because that's how I like to make my coffee. It takes a long time, and I take that three to five minutes and try to move. And so sometimes we have just a few little bursts of opportunity that maybe don't look like formal exercise, I don't go grab my weights, but you can get movement in. So I think first and foremost, anything that you can do, even if it's, okay, if you're sitting here listening to us chatter and you're in this webinar, can you squeeze your butt? Can you lift up your heels? And actually these are called soleus pushups. So lifting up your heels to your toes, pull your shoulders back, do these shoulder presses, all of it counts.

Could you get more bang for your buck doing vigorous? Absolutely. But maybe vigorous isn't where you are, the space, et cetera. If I could have a perfect short intensity exercise, my favorite recommendation is what's called a Tabata. Through the exercise videos that I did with Breastcancer.org, I know we've shared this link, I showed what a Tabata was. It is a high-intensity interval training. Intensity is personal, but we exercised for 20 seconds, followed by 10 seconds of rest and repeated for eight times. It takes four minutes. You get a lot of bang for your buck in that if that is a level that you're at. By the way, that doesn't have to be a burpee or a jumping jack. It could be marching in place. So I think try a little bit more intense because you only have that time you're only going to work for a window, but don't feel like just because you're going to exercise for a minute, it has to be intense, anything that you can do.

The other thing that I would really recommend people to consider is setting up their environment that keep you active. Like we heard, sometimes we exercise and then we sit all day. “But I did my exercise, but now I'm at the computer for seven hours.” So sometimes when we can set up our environment to make these one to two to three minute pieces more accessible, like put your weights out, set a reminder, call somebody, do a laundry, errand, whatever, really goes forward to help you achieve some of those bigger goals. But don't give yourself like, "Oh, I've only exercised for a minute." Say, "I exercised for a minute," and give yourself a little high five and go on with the rest of your day.

Dr. Marisa Weiss: Right, absolutely. And another thing that's really important for people who've had breast cancer is that after you have treatment and usually, let's say surgery on the front of you, your body naturally guards this area and you tend to bring your shoulders in and your elbows out just to protect yourself from people bumping into you. The problem with that is that you can heal in this curved in position. And later on when you're healed up and you're ready to get moving and grooving again, you might find that your shoulders and the tissues are kind of stuck, more stuck in the front, because healing tissues are stiffer and they pull in.

So one of the things that is important to do during the time that you're healing and you're getting started with exercise, the posture is really important. Posture's important anyway, but when you're making your coffee, you can do a little bit of this, little stretch, little stretch. You can wear posture straps on that area, you can get them on Amazon, just to teach your body about keeping your chest open so that you can heal in the open position.

And then later on when you do go to pick up weights, you want to pick up a weight when your body is able to accommodate the weight. You don't want to start picking up weights when you're leaning over like this because your lower back was not designed to hold a lot of load in this position. That's why you want to work with someone who knows what they're doing so that you don't get injured while you're trying to get moving and grooving again.

Okay. So on the topic of safety, of course it's essential. Dr. Potiaumpai, for someone who feels weak, who has problems with balancing, who may have neuropathy with the numbness and tingling in their fingers and toes, what is the most important safety considerations for exercise and fall prevention, since a fall can be so catastrophic?

Dr. Melanie Potiaumpai: Yeah, so fall risk is the biggest thing that we try to prevent when you experience weakness, neuropathy, changes in balance, dizziness, and exercise is effective in helping to reduce all of those things that contribute to fall risk. One of the things that I like to stress to a lot of the patients that I work with is that you need to set aside your ego when you're doing exercises, especially if you're having side effects.

So everyone has this preconceived notion that exercise should be done standing with heavy weights or bands or at a really fast pace, and that's absolutely not the case, especially if you are experiencing side effects already. So seated exercises are going to be your friend, not everything has to be done standing, and that doesn't mean they're less effective or less targeted. So by turning to seated or laying exercises, you're actually increasing how effective your exercises are because you're actually able to minimize the limitations due to the pain or dizziness or weakness you might be feeling. And then you're actually able to complete the full exercise versus trying to do partial of the exercise just because you're standing.

So one of the big things, again, I think Sami will show some modifications, all exercises can be modified to be either seated or laying down. There is no exercise that I have ever come across that you can't do modified to make sure that you reduce your risk of falling from your side effects.

Dr. Marisa Weiss: Yeah. And also just like if you are going to stand up, you can hold on to something.

Dr. Melanie Potiaumpai: Oh yeah.

Dr. Marisa Weiss: And when you move your legs from side to side, in fact, anybody who is just getting started with exercise, is not quite confident of their stability. As you're saying, you're a little off. You're not in your groove. When you're not in your groove, that's when your highest risk of falling is. And we want you to get moving and grooving, but hold on to something so that you're less likely to fall and you feel more confident.

Use music. Music, whenever you can make something fun and engaging, you're going to enjoy it more and it's going to be something you're going to want to repeat. So I don't know how many of you do the Peloton kind of thing. And if there's a particular instructor you like because of the music. So use any of those little things that make it better. And then as Dr. Potiaumpai says, it's not a competition. Put your ego aside. Just moving and grooving is fabulous, that you're here now and that you're determined to get stronger. That's what you need. And just remember, just going from nothing to something is where you're going to get your biggest value. That's really important.

Now, Sami, what do you recommend for people when it comes to, let's say, their footwear so that they're likely to do the exercise that they need without falling or tripping?

Sami Mansfield: Yeah, absolutely. I mean, I think first and foremost, it should be comfortable on your feet. I would say if you've maybe not had new active footwear in a while, I would go to a footwear store or a sports store and try on some different shoes, make sure that they're at the right size because our feet change and you might experience things like swelling. Other than that, I think it's important to have a little bit of cushion, especially if you're experiencing neuropathy, just especially if you might have that fasciitis in your feet or your feet just don't feel great. Make sure you have good socks. Don't forget your socks.

But I also want to make one interesting recommendation. For a long time, we were getting these really fluffy shoes, and they actually do not help your balance because they're so soft and so fluffy, you're kind of weeble-wobbling. So really look for something that's a little bit soft, but not so fluffy cloud-like. And also if you're experiencing joint pain in your knees, which is very common in our community for a multitude of reasons, look for a flat shoe because often they have a little bit of a heel lift. And I know I love to wear some high heels, but man, sometimes my joints don't feel good. So think about flat because that's actually the best position for your body to be able to activate the muscles appropriately.

But other than that, I can't say that I love one brand over another, but sizing, socks, and thinking about that base to me are some of the key things. Also, do notice if you do have any of that neuropathy or tingling in your feet, you want to accommodate that with perhaps either a softer sock, sometimes that tissue helps, or even a little bit more space in the toe box. And give yourself that break because you want to be comfortable as you're exercising.

Dr. Marisa Weiss: Absolutely. I just pulled my shoe off. So the bottom is good because it's got a tread that's going to give me a grip on the floor and it's got a little bit of softness on it, but it's bad because... I'm not exercising in it because there's no back. You don't want to trip by having your shoe fall off. So you do want to wear a sneaker or something that your foot is solid in that shoe, it's not going to fall off.

One more point to make, which as Dr. Potiaumpai said about ego, one thing that's really important to know is that the aches and pains and the fact that you might be deconditioned is not your fault. You could have two days off from your regular life and have your whole routine thrown off and already your body is shutting down its metabolism to try to save energy.

And most people who go through breast cancer have weeks and months of waiting or treatment or tests and procedures and healing. So it's no surprise that your body is not working like you wanted it to. And then during chemo, a lot of times people get a lot of steroids, which can give you weakness in the muscles around your hips and your shoulders and can make your muscles smaller. So I'm just making the point that, don't be critical of yourself like Dr. Potiaumpai said, be kind to yourself. Give yourself grace. This is a habit. It's a practice that you're starting back up again that's going to be for the rest of your life and you want to be safe.

Now, Dr. Potiaumpai, for those people who have, let's say, metastatic breast cancer to bone and they're concerned about, "What can I do? I don't want to cause any problem there." What do you tell your patients who are in that situation?

Dr. Melanie Potiaumpai: For patients who have progressed and have mets and lesions, we still encourage exercise. We rarely ever tell anyone not to exercise. It is now about identifying the safest type of exercise. And again, I lean on the seated exercises and even prone or laying down exercises depending on your energy level and your mobility as well. And it doesn't necessarily mean you have to use weights. It could be body weight exercises, very small movements, it could just be seated exercises with small movements, or it could just be aerobic exercise, walking around your house if it's too cold outside, doing stationary bicycle. That's another one a lot of my patients love to do because it's very low impact, but still aerobic heavy.

So with bone lesions and metastatic disease, we just want to help maintain. Where a lot of times with exercise we're like, we need to reach the next goal, we need to reach the next weight, we need to increase our muscle mass. That's not necessarily always the case with metastatic disease. It's just about maintaining what you currently have. And then if there are increases, that's great. If not, you're maintaining rather than losing if you were to do nothing at all.

Dr. Marisa Weiss: Absolutely. That's great advice. And Sami, for people who may be in a wheelchair or who have difficulty walking, what do you recommend for finding the right modifications to stay active in that setting?

Sami Mansfield: I mean, we just heard now with Dr. Potiaumpai, seated exercise is legitimately challenging. I mean, you can't cheat anything when you're seated. Your core is already in that position. So I think that we really shouldn't be as scared to try things. I mean, certainly you have to think of perhaps where you can exercise if you are in, perhaps, a device such as a wheelchair. It may be difficult to move based upon where the handles are as an example. So can you set up bands with a doorframe? There are some really great tools that help you put a band around a firm door handle or a pole in your house that's very secure, and get really creative.

I do think that for our individuals that have more sedentary time, aerobic exercise is actually often more challenging. It can be more difficult to get your heart rate up. And also because we are spending more time seated or lying, that our strength muscles kind of go on the back burner. So I may encourage you to think about building that strength muscle first, that will help you mobilize yourself, even if it's moving from a wheelchair to the toilet or to your bed. So to keep that ability of your upper body and even your lower body, if able, to be able to move you around in daily life. 

We want to think about exercise, not about exercise, but how can an exercise enhance our quality of life? And so I don't want us to forget really our objectives, which are, yeah, we all want some nice firm muscles that we feel or see, but exercise really is a tool for living well, and that is the objective. Whatever that means to you, that is why we do it.

Dr. Marisa Weiss: That's great. That's great. Now we're having a great conversation, but we need to cover a little bit of ground here. So we've all talked about how important it is to enjoy what you're doing, that this should be something that brings you joy, pleasure, social connectedness. You may want to do it by yourself, you might want to be part of a dancing group or a hiking group or whatever, and it gives you that social connection, do it with a friend. And let me just ask both of you just to get started because people, it’s the getting started that can be so hard. For both of you, we can go through that quickly. Sami, while you're up, why don't you tell us, what do you tell people to help them get started so they can build on their progress?

Sami Mansfield: So I think two sides. I think you hit one thing on the first, which is accountability. Sometimes we shouldn't be accountable to ourselves because we can be busy to do other... I got to do something else. So find an accountability partner, or if you aren't sure and you're not comfortable telling somebody for accountability, put a calendar on your wall and give yourself a nice smiley face or a heart or a gold star, I love gold stars, on that calendar when you do one thing. Use that reward. That, my friends, is called dopamine. Dopamine drives motivation. We also get dopamine from online shopping and sugar, but let's use it in the healthy way. So find the motivation.

Second, I love automating exercise. As an example, we've posted some of our videos that we did here for Breastcancer.org. There are others. I like to put my exercise, even myself in the hands of somebody else. Find a video that all you have to do is push play. Then you don't have to think about the exercise. I don't have to have music. I don't have to have a timer. I just show up. As you're getting started, simplify because also we know that you're experiencing chemo brain, overwhelm, fatigue. You do not need one more decision, so make it simple. And then all you have to do is, as Dr. Weiss would say, move and groove.

Dr. Marisa Weiss: Well, that's great. Okay. And Sami, while I got you, I know you're going to go off in a sec. What would be the one message about exercise and breast cancer that you want people to know from the webinar today?

Sami Mansfield: Oh my gosh, I would say, so I've been doing this work for 23 years almost, right around the corner of 23 years. And I will say to everybody, with the evidence now and we care about living well and living long, this is the best tool. There is nothing, I think, in all of the lifestyle pillars that is as potent as exercise. So when you think about, man, I want to live my best life and I live my longest life, what should I do? I know we talk about nutrition, but it is exercise. It just is so magical. So that's what I want to share with people is anything you do is awesome, and I love that you all are here.

Dr. Marisa Weiss: Well, that's great. Thank you. And how about you, Dr. Potiaumpai? In terms of the one message about exercise and breast cancer that you want people to remember from today?

Dr. Melanie Potiaumpai: I think what I want everyone to take away, and this is based on my personal experience and the research that I do, is that everything about exercise is way less complex and intimidating than anything that's cancer related. The fact that you all learned the different tests that you had to take, medications you have to remember and take and fill and remember appointments and probably argue with insurance companies over and over the years. And you're still here learning about exercise, it just shows how resilient you are.

And exercise is nowhere as complex or as difficult as anything that you probably have already experienced, so it's really not intimidating. Don't look to those other bodybuilding websites or anything that's on the internet. Anything that you do for exercise is for you and you alone. So whatever you want to do, whatever you like to do, then do that and go do it. And any benefit is all for you.

Dr. Marisa Weiss: That's great. I love that. Okay. I want to thank both of you for the invaluable information you shared. And to follow this, I want to have Sami give you a short demonstration of something that you can do, take home and start doing right away.

Sami Mansfield: So I moved into a different space, so you all can see that I have my hard back chair right here. So if you have this, this is great. We're just going to start by sitting in the chair with this really tall posture. And first thing that I want everyone to do is just start lifting up one knee at a time, sitting up really tall. If you want to add your arms into this, you can. So this would actually be considered to be just a chair march.

Now, for those of you that want to stay seated, I want you to actually stay in this position and I want you to keep going, focusing on picking up your legs with a little bit more vigor, kind of driving your knee up to the ceiling. For those of you that want to pick up your intensity and move through full range of motion, you're going to plant your feet slightly wider than shoulder width. You can put hands on your thighs or out, and you're just going to stand up from your chair, squeezing your booty, and back down.

So everybody, we're going to do whatever position that you're in or whatever movement that you're in for about another 20 seconds together. So this is called a sit to stand or a squat. If you have weights, you can hold them, but this is also really great for body weight. If you're feeling more skilled, you can move the chair and just do this without the chair, but I love that chair as I'm also getting warmed up after I've been seated for an hour here listening to us.

Now on this next repetition, I'm going to actually sit back down. And next thing I'm going to do, good posture, I'm going to press my arms into an overhead position. If you have weights and want to use it, I want you to grab these. Now, a couple of things here, I have my elbows wide or I can turn my elbows in slightly to the front so that I'm actually in a V position. My goal here is to get my arms all the way up to my ears, touching the ceiling, and back down.

Now again, you can do this with weight or body weight. We're going to keep going for 30 seconds. If you're getting tired, you can do one arm at a time. If you're feeling like you need a little more intensity, you're going to push your palms facing forward and then you're going to bring your palms facing your nose. So you can add this little curve into that movement. Whatever position you're going to do, we're going to stay here for 15 more seconds. And don't worry, we're going to have an opportunity to try these again. We're going to actually do three rounds of these exercises in a little bit of an interval training today. All right, we're going to go ahead and do two more repetitions wherever you are. Very nice. 

Now, I would love for everybody, if you can, to stand up. If you're seated, you're going to practice squeezing your butt muscles, those muscles that you're sitting on, in a seated position. If you're with me, I'm going to stand behind my chair and I'm just going to step one foot back and the other foot back. So we're going to just take some weight, I'm going to shift it off that front leg, kind of coming into the middle. For those of you that are feeling a little bit more strong today or wanting to try something a little bit more intense, I'm going to come back, I'm going to start to slowly drop that back knee, and then come together. But you don't have to do that.

Now notice I'm using my chair and I'm just working one leg at a time. This challenges my balance and my core. So we're going to stay there. Now remember, if you're seated, you're really squeezing that butt, you should feel your pelvis lift, or you're working with me right here. All right, we're just going to go for five more seconds. Getting that heart rate up just a little bit. 

I'm going back to my chair. I'm just turning it for my convenience. Now I'm going to sit on my chair and we cannot forget the core, so I'm going to lean back, holding it right here.

Now I have three options. You can do whatever you want. Either I can keep my feet on the floor and start to slowly turn, or I can go center and I'm going to lift one leg up at a time using just my lower abdominals. If you want to make this more intense, you can lift both legs, but I'm going to stick on that one leg version myself. Now remember, other option, core tight, and I'm just turning a little bit side to side. So I just want to show you multiple options to engage muscles really virtually from the same position. 

So we're going to stay here for just another 10 seconds. And then we're going to do two quick circuits of these four movements at your level. All right, go ahead and rest. Take a couple of big breaths. 

So here are our four movements. We're going to do two rounds, 30 seconds of each. We're going to sit to stand or march in place. We're going to do the shoulder press. Then we're going to do those step-backs or lunges. And then we're going to do the core position.

All right, we're going in three, two, and begin. So I'm going to do the sit to stand, but again, you can go ahead and do that chair march position. Every time I stand up, I'm standing up nice and tall, shoulders back, squeezing my butt, and then controlling my lower. Hands can be on my thighs if I'm starting to get tired. If I want to pick up the intensity, you're welcome to move faster holding those weights, or I can just go nice and slow, slowing down in that lowering position.

All right, we're switching. If you don't have those weights, grab them, going into that shoulder press position. Again, thinking about nice, tall posture. Shoulder blades are back. Pressing overhead. Very nice. Good work, everybody. Thinking about range of motion first. It doesn't matter how heavy we do. We care about full range of motion. All of those muscles. Last five seconds. Very nice. Give me one more. Good. And relax.

All right. We're going to do the step-backs now. So I'm stepping back. I'm not going to use the chair just because I don't want to spend that time moving the chair, but you're going to hold onto that chair, or I'm going to turn this into a lunge. Notice I'm going to have a nice tall torso. Whatever movement I'm doing, I'm looking right ahead of me. I always say to people, remember, you can be a queen and you're going to put your crown on. So you want to keep that crown on. We don't want that crown to tip off. Last one. 

Back to core. Good. Lean back. Abs are engaged. Option to lift those legs. Option to rotate. Just 30 seconds here. And then we're going to do one more round together. So we'll just have a couple of minutes of exercise left. Take a break whenever you need to. You can even move faster if you're ready. This is your workout. Good work, everybody. Five seconds. Three, two. And rest.

All right. Last set. Sit to stand or squeeze those glutes. Oh no, I'm sorry. Chair march. Chair march. Good. Sitting back down. If you're doing that sit to stand, tighten up those hips every time. Nice job. Now remember, pick your tempo up if you want to go more intense. Slow down if you want that break. Stop whenever you need to. Five seconds. Last one. All right. 

Sitting down, grabbing those weights right into that shoulder press movement. Think about nice full extension. This is where I really work on the posture. As we learned, those chest muscles get tight. Think about sliding up a wall right behind you. Slow and controlled, not going too fast. Nice work, everybody. Last five seconds. You're breathing, taking some good deep breaths. Heart rate is probably elevated.

All right, we're switching last time. Step back or lunges. Remember I'm tapping back or I'm doing those lunges. So I want to tell you, I talked about those types of exercise in the beginning. This little workout is all three. We're getting strength, we're getting aerobic, we're getting that core, and even a little recovery because of range of motion. So we're getting that full bang for your buck. Five seconds. Last three, two. And rest.

All right. Last set is our core. Sitting in that chair, strong position. Shoulders are back. Whatever you want to do. Again, rotations if you want to. Lifting up those legs. I love doing this one at night, watching a little TV. Just working a little bit of that lower body, a little bit of the core. Here we go. Five seconds. Nice. Last three, two. And rest. Nice job, everybody. 

Go and roll those shoulders back. We'll just take about 30 seconds. Big arm circles if you can. Very nice. All right. Take those arms, take a big breath in, and exhale those arms down. All right. One more time. Inhale and big exhale. All right. Great job, everybody. Thank you for joining me in that workout if you tried that.

Dr. Marisa Weiss: That was excellent, Sami. You got us all moving and grooving. Thank you so much. We really appreciate it. 

Before we go, I want to make sure that you all know that on our website, Breastcancer.org, we have a series of free exercise videos that Sami did. So there's more out there for you. We also have interviews with more exercise experts that you can read and listen to and watch. We'll be sending links by email so you can search for that on Breastcancer.org for trusted guidance on exercise, side effects management, and so much more. It's so important that when you work to do exercise to get some guidance and hire a personal trainer or join a group exercise class, that could be an effective way to improve your motivation, consistency, your safety, especially if you're new to this or you're returning to this after treatment.

And for those of you interested in one-on-one support, it's important to check a personal trainer's certifications. You can check them out in the database on the American College of Sports Medicine, the American Council on Exercise, the National Academy of Sports Medicine. And it's always a good idea to find a trainer who has expertise and experience helping people who've had breast cancer because there are some special certifications that they might be able to get that you could benefit from. That's especially true if you're at risk or have lymphedema.

Don't hesitate to interview the trainer and ask pointed questions about their qualifications because you want to find someone who's a good match for you, understands your body, how you're feeling emotionally, and so they can tailor the exercise prescription for your situation. And for someone starting out, like you heard, start low, go slow, and increase your intensity gradually over time. To find free or low cost exercise classes for beginners or for people who have been diagnosed with breast cancer, consider checking out your town or your county community center or recreation department. There might be a local Y where they have a free Livestrong Program.

Your cancer center or the hospital might actually have an exercise or rehab program that you can take advantage of. Of course, there's stuff on YouTube that's been created by reputable medical institutions such as Dartmouth, Johns Hopkins, MD Anderson, Memorial Sloan Kettering. The American Cancer Society has guidelines for exercise that can be done after breast cancer. You can search, again, the American College of Sports Medicine's Moving Through Cancer directory. There's also a free cancer exercise app that was created by Dr. Anna Schwartz. And last, but certainly not least, Sami's six-week online exercise series called reBuild. It's a great opportunity. Everyone here will receive a discount code courtesy of Sami. Thank you. And if a class is not specifically for people who've had breast cancer, let the instructor know ahead of time privately so that you can talk through any concerns you might have. And it's worth mentioning, it's important to check with your doctor again before you start this whole thing up again, make sure if there's any limitations.

And finally, thank you all for coming. We have accomplished a lot today together. We hope to see you at our next webinar in February, What To Eat After a Breast Cancer Diagnosis. You'll get an invitation to register in your email. And thank you again to Sami and Dr. Potiaumpai for sharing their knowledge and compassion to our Breastcancer.org team. 

Remember, exercise doesn't have to be intense to make a difference. Small steps count, gentle steps count, and doing an activity you enjoy also counts. We hope the guidance you've heard today about side effect management, aerobic and strength training, lymphedema precautions, safety considerations, and motivation, all that gives you the confidence to take those first steps or to continue on the path you've already begun because prioritizing your well-being is itself an act of strength, and we're honored to support you along the way. Please take care.