Weight lifting in women with breast-cancer-related lymphedema

Lymphedema

Lymphedema is the chronic, progressive swelling of tissue due to inadequate lymphatic function. Over time, protein-rich fluid accumulates in the tissue, causing it to enlarge. Lymphedema is a specific disease and should not be used as a generic term for an enlarged extremity. The diagnosis is made by evaluating the history and physical examination, and can be confirmed with lymphoscintigraphy. Intervention includes patient education, compression, and, rarely, surgery. Patients are advised to exercise, maintain a normal body mass index, and moisturize/protect the diseased limb from incidental trauma. Conservative management consists of compression regimens. Operative interventions either attempt to address the underlying lymphatic anomaly or the excess tissue. Lymphatic-venous anastomosis and lymph node transfer attempt to create new lymphatic connections to correct the defect. Suction-assisted lipectomy and staged cutaneous/subcutaneous excision reduce the size of the area by removing extra tissues.

The beneficial effect of enhanced physical activity on the welfare of breast cancer survivors

SUMMARY 

Healthcare providers caring for breast cancer survivors can positively impact patients' quality of life by counseling them about lifestyle modifications such as physical activity and exercise. Based on a literature review of current available evidence, this article serves as a guide to primary care providers regarding the beneficial role of lifestyle modification and physical activity. Specific survivorship issues and beneficial impacts of physical activity that will be discussed in this article include the management of arthralgias, cancer related fatigue, lymphedema, pain, mental health conditions, weight management and reducing breast cancer recurrence. The timing and intensity of physical activity needs to be individualized based on patient symptoms, comorbidities and personal preferences. The goals of physical activity options for breast cancer survivors are to aid in the management of treatment-related side effects, improve fitness and maintain a healthy lifestyle.

Yoga management of breast cancer-related lymphoedema: a randomised controlled pilot-trial

Background

Secondary arm lymphoedema continues to affect at least 20% of women after treatment for breast cancer requiring lifelong professional treatment and self-management. The holistic practice of yoga may offer benefits as an adjunct self-management option. The aim of this small pilot trial was to gain preliminary data to determine the effect of yoga on women with stage one breast cancer-related lymphoedema (BCRL). This paper reports the results for the primary and secondary outcomes.

Methods

Participants were randomised, after baseline testing, to receive either an 8-week yoga intervention (n = 15), consisting of a weekly 90-minute teacher-led class and a 40-minute daily session delivered by DVD, or to a usual care wait-listed control group (n = 13). Primary outcome measures were: arm volume of lymphoedema measured by circumference and extra-cellular fluid measured by bioimpedance spectroscopy. Secondary outcome measures were: tissue induration measured by tonometry; levels of sensations, pain, fatigue, and their limiting effects all measured by a visual analogue scale (VAS) and quality of life based on the Lymphoedema Quality of Life Tool (LYMQOL). Measurements were conducted at baseline, week 8 (post-intervention) and week 12 (four weeks after cessation of the intervention).

Results

At week 8, the intervention group had a greater decrease in tissue induration of the affected upper arm compared to the control group (p = 0.050), as well as a greater reduction in the symptom sub-scale for QOL (p = 0.038). There was no difference in arm volume of lymphoedema or extra-cellular fluid between groups at week 8; however, at week 12, arm volume increased more for the intervention group than the control group (p = 0.032).

Conclusions

An 8-week yoga intervention reduced tissue induration of the affected upper arm and decreased the QOL sub-scale of symptoms. Arm volume of lymphoedema and extra-cellular fluid did not increase. These benefits did not last on cessation of the intervention when arm volume of lymphoedema increased. Further research trials with a longer duration, higher levels of lymphoedema and larger numbers are warranted before definitive conclusions can be made.

Impact of resistance training in cancer survivors: a meta-analysis

PURPOSE

Current evidence suggests many health benefits from physical activity during and after cancer treatment. However, the optimal exercise program for cancer survivors has not yet been established. The purpose of this meta-analysis was to summarize evidence for the efficacy of resistance training (RT) interventions to improve muscle strength and body composition among adult cancer survivors. We also investigate potential dose-response relationships between intensity, duration, and frequency of RT and assessed outcomes.

METHODS

A systematic literature review of the Clinical Trial Register, Cochrane Trial Register, MEDLINE, and EMBASE literature databases was undertaken. Studies were included if they were randomized controlled trials (RCT) comparing RT with an exercise or nonexercise control group in cancer survivors during and after treatment. Thirteen articles from 11 RCT met our inclusion criteria. We performed a random-effects meta-analysis to determine weighted mean differences (WMD) with 95% confidence intervals using the Cochrane Review Manager 5.0.25. A random-effects metaregression model was performed to examine dose-response relationships between RT variables and assessed outcomes.

RESULTS

Quantitative evidence shows a large effect of RT on lower-limb and upper-limb muscle strength (WMD: +14.57 kg, P = 0.0005 and +6.90 kg, P < 0.00001, respectively) and moderate effects on lean body mass and percentage of body fat (WMD: +1.07 kg, P < 0.0001 and -2.08%, P = 0.003, respectively). A small positive effect of RT was noted on Functional Assessment of Cancer Therapy-Fatigue (P = 0.05). Upper-limb muscle strength and percentage of body fat improved to a greater extent when RT interventions were of low to moderate intensity (≤ 75% one-repetition maximum, P = 0.042).

CONCLUSIONS

RT was shown to be associated with clinically important positive effects on muscular function and body composition in patients during treatment or in long-term follow-up.

Physical Activity in Breast Cancer Patients during Medical Treatment and in the Aftercare - a Review

Most scientific studies regarding physical activity in cancer patients involve breast cancer patients. It is apparent that physical activity during medical treatment and aftercare is not only feasible and safe but also effective. Current studies clearly show that regular and specific endurance and/or resistance training can reduce a number of side effects caused by medical treatment. Among others, improvements in physical performance, body composition, and quality of life as well as a reduction in fatigue, have been observed. Since inactivity appears to exacerbate lymphedema, patients with lymphedema are also encouraged to exercise. Few studies have been carried out regarding physical exercise in metastatic patients. However, experts in the field also recommend regular physical activity for patients with advanced-stage breast cancer.

Running away from side effects: physical exercise as a complementary intervention for breast cancer patients

The number of breast cancer survivors increases every year, thanks to the development of new treatments and screening techniques. However, patients present with numerous side effects that may affect their quality of life. Exercise has been demonstrated to reduce some of these side effects, but in spite of this, few breast cancer patients know and follow the exercise recommendations needed to remain healthy. In this review, we describe the different breast cancer treatments and the related side effects and implications of exercise in relation to these. We propose that exercise could be an integrative complementary intervention to improve physiological, physical and psychological factors that affect survival and quality of life of these patients. For that reason, the main objective of this review is to provide a general overview of exercise benefits in breast cancer patients and recommendations of how to design exercise interventions in patients with different side effects.

Pain in cancer survivors

Pain is a common problem in cancer survivors, especially in the first few years after treatment. In the longer term, approximately 5% to 10% of survivors have chronic severe pain that interferes with functioning. The prevalence is much higher in certain subpopulations, such as breast cancer survivors. All cancer treatment modalities have the potential to cause pain. Currently, the approach to managing pain in cancer survivors is similar to that for chronic cancer-related pain, pharmacotherapy being the principal treatment modality. Although it may be appropriate to continue strong opioids in survivors with moderate to severe pain, most pain problems in cancer survivors will not require them. Moreover, because more than 40% of cancer survivors now live longer than 10 years, there is growing concern about the long-term adverse effects of opioids and the risks of misuse, abuse, and overdose in the nonpatient population. As with chronic nonmalignant pain, multimodal interventions that incorporate nonpharmacologic therapies should be part of the treatment strategy for pain in cancer survivors, prescribed with the aim of restoring functionality, not just providing comfort. For patients with complex pain issues, multidisciplinary programs should be used, if available. New or worsening pain in a cancer survivor must be evaluated to determine whether the cause is recurrent disease or a second malignancy. This article focuses on patients with a history of cancer who are beyond the acute diagnosis and treatment phase and on common treatment-related pain etiologies. The benefits and harms of the various pharmacologic and nonpharmacologic options for pain management in this setting are reviewed.

The muscle mass, omega-3, diet, exercise and lifestyle (MODEL) study - a randomised controlled trial for women who have completed breast cancer treatment

Background

Loss of lean body mass (LBM) is a common occurrence after treatment for breast cancer and is related to deleterious metabolic health outcomes [Clin Oncol, 22(4):281–288, 2010; Appl Physiol Nutr Metab, 34(5):950–956, 2009]. The aim of this research is to determine the effectiveness of long chain omega-3 fatty acids (LCn-3s) and exercise training alone, or in combination, in addressing LBM loss in breast cancer survivors.

Methods/design

A total of 153 women who have completed treatment for breast cancer in the last 12 months, with a Body Mass Index (BMI) of 20 to 35 kg/m², will be randomly assigned to one of 3 groups: 3g/d LCn-3s (N-3), a 12-week nutrition and exercise education program plus olive oil (P-LC) or the education program plus LCn-3s (EX+N-3). Participants randomised to the education groups will be blinded to treatment, and will receive either olive oil placebo (OO+N-3) or LCn-3 provision, while the N-3 group will be open label. The education program includes nine 60-75min sessions over 12 weeks that will involve breast cancer specific healthy eating advice, plus a supervised exercise session run as a resistance exercise circuit. They will also be advised to conduct the resistance training and aerobic training 5 to 7 days per week collectively. Outcome measures will be taken at baseline, 12-weeks and 24-weeks. The primary outcome is % change in LBM as measured by the air displacement plethysmograhy. Secondary outcomes include quality of life (FACT-B + 4) and inflammation (C-Reactive protein: CRP). Additional measures taken will be erythrocyte fatty acid analysis, fatigue, physical activity, menopausal symptoms, dietary intake, joint pain and function indices.

Discussion

This research will provide the first insight into the efficacy of LCn-3s alone or in combination with exercise in breast cancer survivors with regards to LBM and quality of life. In addition, this study is designed to improve evidence-based dietetic practice, and how specific dietary prescription may link with appropriate exercise interventions.

Trials registration

ACTRN12610001005044; and World Health Organisation Universal trial number: U1111-1116-8520.

Randomized controlled trial to evaluate the effects of combined progressive exercise on metabolic syndrome in breast cancer survivors: rationale, design, and methods

Background

Metabolic syndrome (MetS) is increasingly present in breast cancer survivors, possibly worsened by cancer-related treatments, such as chemotherapy. MetS greatly increases risk of cardiovascular disease and diabetes, co-morbidities that could impair the survivorship experience, and possibly lead to cancer recurrence. Exercise has been shown to positively influence quality of life (QOL), physical function, muscular strength and endurance, reduce fatigue, and improve emotional well-being; however, the impact on MetS components (visceral adiposity, hyperglycemia, low serum high-density lipoprotein cholesterol, hypertriglyceridemia, and hypertension) remains largely unknown. In this trial, we aim to assess the effects of combined (aerobic and resistance) exercise on components of MetS, as well as on physical fitness and QOL, in breast cancer survivors soon after completing cancer-related treatments.

Methods/Design

This study is a prospective randomized controlled trial (RCT) investigating the effects of a 16-week supervised progressive aerobic and resistance exercise training intervention on MetS in 100 breast cancer survivors. Main inclusion criteria are histologically-confirmed breast cancer stage I-III, completion of chemotherapy and/or radiation within 6 months prior to initiation of the study, sedentary, and free from musculoskeletal disorders. The primary endpoint is MetS; secondary endpoints include: muscle strength, shoulder function, cardiorespiratory fitness, body composition, bone mineral density, and QOL. Participants randomized to the Exercise group participate in 3 supervised weekly exercise sessions for 16 weeks. Participants randomized to the Control group are offered the same intervention after the 16-week period of observation.

Discussion

This is the one of few RCTs examining the effects of exercise on MetS in breast cancer survivors. Results will contribute a better understanding of metabolic disease-related effects of resistance and aerobic exercise training and inform intervention programs that will optimally improve physiological and psychosocial health during cancer survivorship, and that are ultimately aimed at improving prognosis.

Trial registration

NCT01140282; Registration: June 10, 2010

Evidence-based recommendations for building better bras for women treated for breast cancer

Participating in exercise is beneficial for women who have been treated for breast cancer. However, not being able to find a comfortable exercise bra can be a barrier to exercise participation. This study aimed to systematically investigate what breast support women treated for breast cancer want when they exercise in order to provide evidence-based recommendations to improve exercise bra designs for these women. Based on 432 responses from a national online survey, frequency and relationship data were analysed (binary logistic regression) to understand exercise bra issues pertinent to this population. These issues included being able to control for asymmetrical cup sizes, managing heightened skin sensitivity, managing fluid (size) fluctuations, managing a prosthesis and restoring body image by restoring shape. This study provides evidence-based recommendations to inform an exercise bra design that will meet the unique needs of women treated for breast cancer. Rigorous, evidence-based evaluations of exercise bras for women treated for breast cancer may contribute to their well-being and quality of life through enhanced designs.

Development and evaluation of the Korean version of the Gynecologic Cancer Lymphedema Questionnaire in gynecologic cancer survivors

OBJECTIVE

The purpose of this study was two-fold: first, to develop a Korean version of the Gynecologic Cancer Lymphedema Questionnaire (GCLQ-K) and evaluate its reliability and reproducibility and second, to examine the diagnostic efficacy of GCLQ-K in predicting lymphedema in gynecologic cancer survivors.

METHODS

We designed a case-control study, and the GCLQ-K was completed by 33 gynecologic cancer survivors with lymphedema and 34 gynecologic cancer survivors without lymphedema. A follow-up GCLQ-K was completed 3weeks after the baseline questionnaire.

RESULTS

The GCLQ-K showed high reliability with a Cronbach's α of 0.83 and high reproducibility with an intraclass correlation of 0.96. Of the 7 symptom clusters, 6 identified patients with lymphedema with statistical significance; identification of lymphedema using the physical functioning and infection-related symptom clusters did not reach significance. The area under the receiver operating characteristic curve (AUC) to distinguish patients with and without lymphedema was 0.868 (95% confidence interval [CI], 0.779-0.956). Following the exclusion of the physical functioning and infection-related symptom clusters, which showed poor prediction value for lymphedema, the AUC of the GCLQ-K total score further improved to 0.922 (95% CI, 0.864-0.981).

CONCLUSION

The GCLQ-K was successfully developed with minimal modifications to adapt the original GCLQ to the Korean culture and showed high internal consistency and reproducibility. Moreover, gynecologic cancer survivors with and without lymphedema could be satisfactorily distinguished using the GCLQ-K. Thus, GCLQ-K was proven to be a reliable tool, capable of identifying lymphedema in Korean gynecological cancer survivors.

Heavy resistance training and lymphedema: prevalence of breast cancer-related lymphedema in participants of an exercise intervention utilizing heavy load resistance training

BACKGROUND

There is limited knowledge regarding progressive resistance training during adjuvant chemotherapy and the risk of developing breast cancer-related lymphedema (BCRL). Furthermore, no studies have investigated the safety of resistance training with heavy loads (> 80% 1 repetition maximum) in this population. 'Body and Cancer' is a six-week, nine-hour weekly, supervised, multimodal exercise intervention utilizing progressive resistance training with heavy loads for cancer patients undergoing chemotherapy. The purpose of the present study was to estimate the prevalence of BCRL in former participants, and identify associations between progressive resistance training with heavy loads, and the development of BCRL.

MATERIAL AND METHODS

This was a descriptive study.

POPULATION

Women treated for breast cancer (n = 149), who had participated in the 'Body and Cancer' exercise intervention between 1 January 2010 and 31 December 2011 participated in a structured telephone interview. The average follow-up time was 14 months (range 4-26). A clinical diagnosis of BCRL reported by the participant was the primary outcome.

RESULTS

A total of 27.5% reported that they had been diagnosed with BCRL by a clinician. This was true for 44.4% with axillary node dissection. No statistically significant association between strength gains during the exercise intervention, and the development of BCRL was observed, nor was self-reported participation in progressive resistance training with heavy loads up to three months post-intervention.

CONCLUSION

The prevalence of BCRL among former "Body and Cancer" participants at follow-up was 27.5%. There appears to be no association between performing heavy resistance training during adjuvant treatment (chemotherapy/radiotherapy), and the development of BCRL. However randomized controlled trials should be performed to confirm this observation.

Association of obesity and circulating adipose stromal cells among breast cancer survivors

A positive association of obesity with breast cancer incidence and mortality is well established. Recent reports indicate that adipose stromal cells (ASCs) play an important role in breast cancer development and progression by producing estrogens and tumor-promoting cytokines. Furthermore, circulating ASCs have been uniquely detected in obese individuals, which is likely due to increased tissue remodeling and cell mobilization. The number of circulating ASCs is even more prominent in obese patients with colon and prostate cancers, both of which are exacerbated by obesity. To determine whether a similar association exists for breast cancer, we collected blood samples from a cohort of breast cancer survivors and enumerated circulating ASCs by flow cytometry on the basis of the previously established ASC-associated immunophenotype (CD34+/CD31-/CD45-). We found significantly higher levels of circulating ASCs (p<0.001) in breast cancer survivors with body mass index (BMI)≥30 kg/m2 than their non-obese counterparts (BMI<30). We also compared circulating ASCs before and after exercise of only the obese subjects enrolled in a 6-month individualized exercise program, but found no statistically significant difference, likely due to limited number of subjects in the study. Our findings suggest that circulating ASCs can serve as a potential biomarker for future studies of the impacts of obesity and physical activity on breast cancer recurrence and survival.

Influence of weight training on skeletal health of breast cancer survivors with or at risk for breast cancer-related lymphedema

PURPOSE

This study aimed to determine whether the Physical Activity and Lymphedema (PAL) trial weight training program for breast cancer survivors at risk of or with breast cancer-related lymphedema provided skeletal benefits.

METHODS

Of the 295 participants in the randomized controlled PAL trial, 258 (weight training; N = 128; control, N = 130) had complete measures of bone mineral density (BMD (in grams per square centimeter)) of the proximal femur and lumbar spine and were also categorized by T scores. Women in the weight training group performed slowly progressive weight training 2 days/week for 12 months compared to women in the control group who maintained their usual physical activities.

RESULTS

There were no significant differences in the rate of BMD change at any skeletal site between weight training and control groups, regardless of menopausal status. Distribution of bone health categories was not significantly different between groups at baseline, but became different at 12 months (p < 0.03) among postmenopausal women due to an increase in the percentage of controls who became osteopenic (35 to 44%) compared to stable bone health in weight lifters.

CONCLUSIONS

The PAL weight training program that increased muscle strength without exacerbating or causing lymphedema among breast cancer survivors was not as efficacious at improving skeletal health. The skeletal loads produced from the PAL program may be insufficient to notably shift BMD, but may have a subtle osteogenic effect.

IMPLICATIONS FOR CANCER SURVIVORS

The safety and efficacy of rigorous weight training programs for improving skeletal health in women at risk for or with breast cancer-related lymphedema remain to be determined.

Musculoskeletal changes after 1 year of exercise in older breast cancer survivors

INTRODUCTION

We have previously reported that 1 year of supervised resistance + impact training stopped bone loss and built muscle strength in older breast cancer survivors. The purpose of this study was to determine whether these benefits persisted 1 year after completion of the intervention.

METHODS

Sixty-seven women from the original trial completed baseline and post-intervention body composition and muscle strength tests, and 44 women were available 1 year later for follow-up assessments. Bone mineral density (grams per square centimeter) of the hip and spine, muscle mass (kilograms), and fat mass (kilograms) were measured by dual-energy X-ray absorptiometry and maximal upper and lower body strength were measured by one-repetition maximum tests (kilograms). We compared between group changes across baseline (pre-intervention), 1 (post-intervention), and 2 years (1 year follow up) on study outcomes using repeated-measures analysis of covariance, adjusting for age.

RESULTS

Significant group by time interactions were found for spine bone mineral density (BMD) (p < 0.01) and lower body muscle strength (p < 0.05), with a trend for upper body muscle strength (p = 0.05). Spine BMD remained stable across intervention and follow-up periods in exercisers compared with continuous losses in controls across 1- and 2-year periods. In contrast, lower body strength increased in exercisers across the intervention, but decreased to near-baseline levels during follow-up compared with no change over either time period in controls.

CONCLUSIONS

Our data suggest that spine BMD can be preserved in older breast cancer survivors even after formal exercise training stops; however, muscle strength is not similarly maintained and may require continued participation in a supervised exercise program.

IMPLICATIONS FOR CANCER SURVIVORS

Exercise programs aimed at improving musculoskeletal health should be considered in the long-term care plan for breast cancer survivors.

Physical activity and lower limb lymphedema among uterine cancer survivors

PURPOSE

Physical activity (PA) is known to provide physical and mental health benefits to uterine cancer survivors. However, it is unknown if PA is associated with lower limb lymphedema (LLL), an accumulation of protein-rich fluid in the lower limbs. Therefore, we sought to examine the association between PA and LLL in uterine cancer survivors, with a focus on walking.

METHODS

We conducted a cross-sectional study using mailed surveys among uterine cancer survivors who received care at a university-based cancer center. We asked about PA, walking, and LLL symptoms using validated self-report questionnaires. PA was calculated using MET-hours per week, and walking was calculated using blocks per day.

RESULTS

The response rate to our survey was 43%. Among the 213 uterine cancer survivors in our survey, 36% were classified as having LLL. Compared with participants who reported <3 MET · h · wk of PA, participants who reported ≥ 18.0 MET · h · wk of PA had an odds ratio of LLL of 0.32 (95% confidence interval, 0.15-0.69; P trend = 0.003). Stratified analyses suggested the association between PA and LLL existed only among women with body mass index (BMI) <30 kg · m (P trend = 0.007) compared with women with BMI ≥ 30 kg · m (P trend = 0.47). Compared with participants who reported <4.0 blocks per day of walking, participants who reported ≥ 12 blocks per day of walking had an odds ratio of LLL of 0.19 (95% confidence interval, 0.09-0.43; P trend < 0.0001). Stratified analyses suggested the association between walking and LLL was similar among women with BMI <30 kg · m (P trend = 0.007) and women with BMI ≥ 30 kg · m (P trend = 0.03).

CONCLUSION

Participation in higher levels of PA or walking is associated with reduced proportions of LLL in dose-response fashion. These findings should be interpreted as preliminary and should be investigated in future studies.

Exercise for breast cancer survivors: bridging the gap between evidence and practice

Evidence supporting the benefits of exercise following the diagnosis of breast cancer is overwhelming and compelling. Exercise reduces the severity and number of treatment-related side effects, optimizes quality of life during and following treatment, and may optimize survival. Yet, exercise does not uniformly form part of the standards of care provided to women following a breast cancer diagnosis. This commentary summarizes the evidence in support of exercise as a form of adjuvant treatment and identifies and discusses potential issues preventing the formal integration of exercise into breast cancer care. Proposed within the commentary is a model of breast cancer care that incorporates exercise prescription as a key component but also integrates the need for surveillance and management for common breast cancer treatment-related morbidities, as well as education. While future research evaluating the potential cost savings through implementation of such a model is required, a committed, collaborative approach by clinicians, allied health professionals, and researchers will be instrumental in bridging the gap between research and practice.

Interventions for promoting habitual exercise in people living with and beyond cancer

BACKGROUND

The beneficial effects of regular exercise for people living with or beyond cancer are becoming apparent. However, how to promote exercise behaviour in sedentary cancer cohorts is not as well understood. A large majority of people living with or recovering from cancer do not meet exercise recommendations. Hence, reviewing the evidence on how to promote and sustain exercise behaviour is important.

OBJECTIVES

To assess the effects of interventions to promote exercise behaviour in sedentary people living with and beyond cancer and to address the following questions: Which interventions are most effective in improving aerobic fitness and skeletal muscle strength and endurance? What adverse effects are attributed to different exercise interventions? Which interventions are most effective in improving exercise behaviour amongst patients with different cancers? Which interventions are most likely to promote long-term (12 months or longer) exercise behaviour? What frequency of contact with exercise professionals is associated with increased exercise behaviour? What theoretical basis is most often associated with increased exercise behaviour? What behaviour change techniques are most often associated with increased exercise behaviour?

SEARCH METHODS

We searched the following electronic databases: Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 8, 2012), MEDLINE, EMBASE, AMED, CINAHL, PsycLIT/PsycINFO, SportDiscus and PEDro from inception to August 2012. We also searched the grey literature, wrote to leading experts in the field, wrote to charities and searched reference lists of other recent systematic reviews.

SELECTION CRITERIA

We included only randomised controlled trials (RCTs) that compared an exercise intervention with a usual care approach in sedentary people over the age of 18 with a homogenous primary cancer diagnosis.

DATA COLLECTION AND ANALYSIS

Two review authors working independently (LB and KH) screened all titles and abstracts to identify studies that might meet the inclusion criteria, or that cannot be safely excluded without assessment of the full text (e.g. when no abstract is available). All eligible papers were formally abstracted by at least two members of the review author team working independently (LB and KH) and using the data collection form. When possible, and if appropriate, we performed a fixed-effect meta-analysis of study outcomes. For continuous outcomes (e.g. cardiorespiratory fitness), we extracted the final value, the standard deviation of the outcome of interest and the number of participants assessed at follow-up in each treatment arm, to estimate standardised mean difference (SMD) between treatment arms. SMD was used, as investigators used heterogeneous methods to assess individual outcomes. If a meta-analysis was not possible or was not appropriate, we synthesised studies as a narrative.

MAIN RESULTS

Fourteen trials were included in this review, involving a total of 648 participants. Only studies involving breast, prostate or colorectal cancer were identified as eligible. Just six trials incorporated a target level of exercise that could meet current recommendations. Only three trials were identified that attempted to objectively validate independent exercise behaviour with accelerometers or heart rate monitoring. Adherence to exercise interventions, which is crucial for understanding treatment dose, is often poorly reported. It is important to note that the fundamental metrics of exercise behaviour (i.e. frequency, intensity and duration, repetitions, sets and intensity of resistance training), although easy to devise and report, are seldom included in published clinical trials.None of the included trials reported that 75% or greater adherence (the stated primary outcome for this review) of the intervention group met current aerobic exercise recommendations at any given follow-up. Just two trials reported six weeks of resistance exercise behaviour that would meet the guideline recommendations. However, three trials reported adherence of 75% or greater to an aerobic exercise goal that was less than the current guideline recommendation of 150 minutes per week. All three incorporated both supervised and independent exercise components as part of the intervention, and none placed restrictions on the control group in terms of exercise behaviour. These three trials shared programme set goals and the following behaviour change techniques: generalisation of a target behaviour; prompting of self-monitoring of behaviour; and prompting of practise. Despite the uncertainty surrounding adherence in many of the included trials, interventions caused improvements in aerobic exercise tolerance at 8 to 12 weeks (from 7 studies, SMD 0.73, 95% confidence interval (CI) 0.51 to 0.95) in intervention participants compared with controls. At six months, aerobic exercise tolerance was also improved (from 5 studies, SMD 0.70, 95% CI 0.45 to 0.94), but it should be noted that four of the five trials used in this analysis had a high risk of bias, hence caution is warranted in interpretation of results. Attrition over the course of these interventions is typically low (median 6%).

AUTHORS' CONCLUSIONS

Interventions to promote exercise in cancer survivors who report better levels of adherence share some common behaviour change techniques. These involve setting programme goals, prompting practise and self-monitoring and encouraging participants to attempt to generalise behaviours learned in supervised exercise environments to other, non-supervised contexts. However, expecting most sedentary survivors to achieve current guideline recommendations of at least 150 minutes per week of aerobic exercise is likely to be unrealistic. As with all well-designed exercise programmes in any context, prescriptions should be designed around individual capabilities, and frequency, duration and intensity or sets, repetitions, intensity or resistance training should be generated on this basis.

The effect of progressive resistance training on lean body mass in post-treatment cancer patients - a systematic review

Loss of lean body mass is a common problem in many post-treatment cancer patients and may negatively affect physical capacity in terms of maximal muscle strength and functional performance. The purpose of this study was to systematically review the scientific evidence on the effect of progressive resistance training on lean body mass in post-treatment cancer patients. A comprehensive literature search was conducted and ultimately 12 studies were included. Methodological quality of the included studies was evaluated using the PEDro scale and the effect of progressive resistance training was reported as the range of mean changes among RCTs and non-RCTs. Six RCTs and six non-RCTs were included in the study. In the RCTs the change in lean body mass in the progressive resistance training groups relative to control groups ranged from -0.4% to 3.9%, and in four of six trials the training effect was significantly larger than the change in the control groups. In the six non-RCTs, the mean change in lean body mass over time ranged from -0.01 to 11.8% which was significant in two of the trials. The included studies reported no or very limited adverse events following progressive resistance training. Based on 12 heterogenic studies there is moderate evidence supporting a positive effect of progressive resistance training on lean body mass in post-treatment cancer patients.

Prescription and adherence to lymphedema self-care modalities among women with breast cancer-related lymphedema

PURPOSE

To profile the prescription for and adherence to breast cancer-related lymphedema (BCRL) self-care modalities among breast cancer (BrCa) survivors with BCRL in a 12-month randomized weightlifting trial.

METHODS

We developed a questionnaire that assessed prescription for and adherence to 10 BCRL self-care modalities that included physical therapy exercise, pneumatic compression pump, medication, lymphedema bandaging, arm elevation, self-administered lymphatic drainage, therapist-administered lymphatic drainage, compression garments, skin care, and taping. We measured prescription for and adherence to BCRL self-care modalities at baseline, 3, 6, and 12 months. Longitudinal logistic regression was used to estimate the odds ratio (OR) and 95 % confidence interval (95 % CI) associated with prescription for and adherence to BCRL modalities over time.

RESULTS

This study included 141 BrCa survivors with BCRL. Women were prescribed an average of 3.6 ± 2.1 BCRL self-care modalities during the study. The prescription for therapist-administered lymphatic drainage (OR = 0.92, 95 % CI 0.88-0.96), pneumatic compression pump use (OR = 0.94, 95 % CI 0.89-0.98), and bandaging (OR = 0.96, 95 % CI 0.93-0.99) decreased over 12 months of follow-up. No other prescribed BCRL self-care modalities changed during the study. Over 12 months, the average adherence to all BCRL self-care modalities varied with 13, 24, 32, and 31 % of women reporting <25, 25-49, 50-74, and ≥75 % adherence, respectively. Over 12 months, there was a noticeable change from high to low adherence in self-administered lymphatic drainage, such that there was a 15 % increased likelihood of adherence <25 % compared to ≥75 % (OR = 1.15 (95 % CI 1.05-1.26); p = 0.002). The adherence patterns of all other modalities did not change over follow-up.

CONCLUSIONS

Our findings suggest the prescription for BCRL self-care modalities is variable. The average adherence to BCRL self-care was non-optimal. Future research is necessary to prepare BrCa survivors with the knowledge, skills, abilities, and resources necessary to care for this lifelong condition.

Impairment-driven cancer rehabilitation: an essential component of quality care and survivorship

Adult cancer survivors suffer an extremely diverse and complex set of impairments, affecting virtually every organ system. Both physical and psychological impairments may contribute to a decreased health-related quality of life and should be identified throughout the care continuum. Recent evidence suggests that more cancer survivors have a reduced health-related quality of life as a result of physical impairments than due to psychological ones. Research has also demonstrated that the majority of cancer survivors will have significant impairments and that these often go undetected and/or untreated, and consequently may result in disability. Furthermore, physical disability is a leading cause of distress in this population. The scientific literature has shown that rehabilitation improves pain, function, and quality of life in cancer survivors. In fact, rehabilitation efforts can ameliorate physical (including cognitive) impairments at every stage along the course of treatment. This includes prehabilitation before cancer treatment commences and multimodal interdisciplinary rehabilitation during and after acute cancer treatment. Rehabilitation appears to be cost-effective and may reduce both direct and indirect health care costs, thereby reducing the enormous financial burden of cancer. Therefore, it is critical that survivors are screened for both psychological and physical impairments and then referred appropriately to trained rehabilitation health care professionals. This review suggests an impairment-driven cancer rehabilitation model that includes screening and treating impairments all along the care continuum in order to minimize disability and maximize quality of life.

Lymphedema following treatment for breast cancer: a new approach to an old problem

Lymphedema following treatment for breast cancer can be an irreversible condition with a profound negative impact on quality of life. The lack of consensus regarding standard definitions of clinically significant lymphedema and optimal methods of measurement and quantification are unresolved problems. Inconsistencies persist regarding the appropriate timing of intervention and what forms of treatment should be the standard of care. There are reports that early detection and intervention can prevent progression, however,the Level 1 evidence to support this hypothesis has yet to be generated. To assess these controversies, we propose the implementation of a screening program to detect early lymphedema in conjunction with a randomized, prospective trial designed to generate Level 1 evidence regarding the efficacy of early intervention and appropriate treatment strategies. Collaboration among institutions that manage breast cancer patients is essential to establish a standardized approach to lymphedema and to establish guidelines for best practice.

Effects of qigong exercise on upper limb lymphedema and blood flow in survivors of breast cancer: a pilot study

HYPOTHESIS

Qigong exercise is a popular method for relieving the side effects of conventional cancer treatments in survivors of breast cancer, yet its effects are not empirically assessed. This study aimed to investigate the effects of qigong exercise on upper limb lymphedema, arterial resistance, and blood flow velocity in survivors with breast cancer and mastectomy.

STUDY DESIGN

This study was conducted as a prospective clinical trial.

METHODS

Eleven survivors of breast cancer with qigong experience (mean age = 58.3 ± 10.1 years) were assigned to the experimental group and 12 survivors of breast cancer without qigong experience (mean age = 53.8 ± 4.2 years) were assigned to the control group. They all had breast cancer-related lymphedema. All procedures were completed within one session. After baseline measurements were taken, the experimental group performed 18 Forms Tai Chi Internal Qigong for approximately 6 minutes while the control group rested for similar duration in a sitting position. Both groups were then reassessed. All participants were measured on their affected upper limb circumference (by using tape measures), peripheral arterial resistance, and blood flow velocities (using a Doppler ultrasound machine).

RESULTS

The between-group differences were not significant for all outcome measures at baseline (P > .05). The circumferences of the affected upper arm, elbow, forearm and wrist decreased after qigong exercise (P < .05). However, no significant difference was found in the circumference measures between the 2 groups posttest (P > .0125). In terms of vascular outcomes, the resistance index decreased and the maximum systolic arterial blood flow velocity (SV) and minimum diastolic arterial blood flow velocity (DV) increased significantly after qigong exercise (P < .05). The between-group difference was close to significant for SV (P = .018) and was significant for DV (P < .001) posttest.

CONCLUSION

Qigong exercise could reduce conventional cancer therapy side effects such as upper limb lymphedema and poor circulatory status in survivors of breast cancer. However, such effects may be temporary, and further studies must be conducted to explore longer term effects.

Effects of exercise on angiogenesis and apoptosis-related molecules, quality of life, fatigue and depression in breast cancer patients

The aim of this study was to explore the effects of exercise on angiogenesis and apoptosis-related molecules, quality of life, fatigue and depression in patients who completed breast cancer treatment. Sixty breast cancer patients were randomised into three groups, as supervised exercise group, home exercise group and education group. Angiogenesis and apoptosis-related cytokine levels and quality of life (EORTC QOL-C30: European Organisation for Research and Treatment of Cancer Quality of Life C30), fatigue (Brief Fatigue Inventory) and depression (BDI: Beck Depression Inventory) scores were compared before and after a 12-week exercise programme. After the exercise programme, statistically significant decreases were found in interleukin-8 and neutrophil activating protein-78 levels in the home exercise group (P < 0.05). The education group showed a statistically significant increase in monocyte chemoattractant protein-1 level (P < 0.05). Functional score and global health score of EORTC QOL-C30 in the supervised exercise group and functional score of EORTC QOL-C30 in the home exercise group increased significantly after exercise programme (P < 0.05). BDI score was significantly lower in the supervised exercise group after the exercise programme (P < 0.05). Changes in angiogenesis and apoptosis-related molecules in the study groups suggest a possible effect of exercise on these parameters. Exercise programmes are safe and effective on quality of life and depression in breast cancer patients whose treatments are complete.

Interventions to promote energy balance and cancer survivorship: priorities for research and care

The growing population of cancer survivors worldwide and the growing epidemics of obesity and physical inactivity have brought increased attention to the role that interventions to promote exercise and a healthy body weight may play in mitigating the chronic and late effects of cancer. In this light, the authors describe the similarities and differences in research and clinical priorities related to energy balance interventions among post-treatment cancer survivors in Europe versus North America. Randomized controlled trials that targeted nutrition, exercise, and weight are reviewed to determine the affect on survivorship outcomes. Interventions focused on improving prognosis or survival are investigated along with the emerging literature on the interventions targeting pathways and mechanisms of prognosis or survival. Current North American and European guidelines for diet, exercise, and weight control among cancer survivors also are investigated along with the implications of the current state of this science for clinical care. Finally, the authors delineate future European and American priorities for research and care involving energy balance among survivors. It is hoped that this dialogue launches an international conversation that will lead to better research and care for all post-treatment cancer survivors.

Exercise in the prevention and rehabilitation of breast cancer

Breast cancer is the most common type of cancer among women worldwide. Several epidemiological studies have shown an inverse relationship between the risk of breast cancer and physical activity levels, whereas exercise training has been recognized as a significant means in the rehabilitation process of breast cancer survivors. The relative risk reduction of breast cancer for women who engaged in moderate to vigorous physical activity for 3-5 days peek week ranged between 20-40 %. Furthermore, several studies demonstrated a 24-67 % reduction in the risk of total deaths and 50-53 % reduction in the risk of breast cancer deaths in women who are physically active after breast cancer diagnosis compared with sedentary women. Breast cancer survivors should be encouraged to participate in rehabilitation programs in order to obtain numerous physiological and psychological benefits. These include reductions in fatigue and improvements in immune function, physical functioning, body composition, and quality of life. Based on recent scientific evidence, a complete rehabilitation program for patients with breast cancer should combine both strength and aerobic exercise in order to maximize the expected benefits.

Impact + resistance training improves bone health and body composition in prematurely menopausal breast cancer survivors: a randomized controlled trial

Our randomized controlled trial in prematurely menopausal breast cancer survivors showed that impact + resistance training prevented increases in percentage of body fat compared with controls and also improved BMD at the hip and prevented BMD loss at the spine among exercise-trained women who were menopausal for >1 year.

INTRODUCTION

Cancer treatment-related menopause worsens bone health and body composition in breast cancer survivors (BCS). We investigated whether impact + resistance training could improve bone mineral density (BMD), reduce bone turnover, build muscle, and decrease fat mass in BCS with premature menopause.

METHODS

We conducted a randomized controlled trial in 71 BCS (mean age, 46.5 years) within 5 years of treatment-related menopause. Women were randomly assigned to one of two groups: (1) impact + resistance training (prevent osteoporosis with impact + resistance (POWIR)) or (2) exercise placebo (FLEX) 3×/week for 1 year. Outcomes were hip and spine BMD (in grams per square centimeter) and body composition (percent body fat (%BF) and lean and fat mass (in kilograms)) by DXA and bone turnover markers (serum osteocalcin (in nanograms per milliliter) and urinary deoxypryrodinoline (in nanomoles per milliliter).

RESULTS

There were no significant group × time interactions for bone outcomes when using an intent-to-treat approach on the full sample. In analyses restricted to BCS who were menopausal for ≥1 year, POWIR increased BMD at the hip and slowed BMD loss at the spine compared with FLEX (femoral neck-POWIR, 0.004 ± 0.093 g/cm(2) vs. FLEX, -0.010 ± 0.089 g/cm(2); p < 0.01; spine-POWIR, -0.003 ± 0.114 g/cm(2) vs. FLEX, -0.020 ± 0.110 g/cm(2); p = 0.03). POWIR prevented increases in %BF (POWIR, 0.01 % vs. FLEX, 1.3 %; p < 0.04). Women with attendance to POWIR at ≥64 % had better improvements in %BF than women attending less often (p < 0.03).

CONCLUSION

Impact + resistance training may effectively combat bone loss and worsening body composition from premature menopause in BCS.

Is it safe and efficacious for women with lymphedema secondary to breast cancer to lift heavy weights during exercise: a randomised controlled trial

PURPOSE

Resistance exercise has great potential to aid in the management of breast cancer-related lymphedema (BCRL); however, little is known regarding optimal exercise prescription. The pervasive view is that resistance exercise with heavy loads may be contraindicated, disregarding the dose-response relationship that exists between the load utilised in resistance exercise and the magnitude of structural and functional improvements. No previous research has examined various resistance exercise prescriptions for the management of BCRL. This study compared the effects of high load and low load resistance exercise on the extent of swelling, severity of symptoms, physical function and quality of life in women with BCRL.

METHODS

Sixty-two women with a clinical diagnosis of BCRL (>5 % inter-limb discrepancy) were randomly assigned to a high-load resistance exercise (n = 22), low-load resistance exercise (n = 21) or usual care (n = 19) group. Participants in the experimental groups completed a 3-month moderate- to high-intensity resistance exercise program in which the load of the exercises was manipulated from 10-6 repetition maximum (75-85 % of one repetition maximum [1RM]) for the high-load group or from 20-15 repetition maximum (55-65 % 1RM) for the low-load group. Outcome measures included the extent of swelling in the affected arm, symptom severity, physical function and quality of life.

RESULTS

There were no differences between groups in the extent of affected arm swelling or severity of symptoms. The change in muscle strength, muscle endurance and quality of life-physical functioning was significantly greater in both high-load and low-load groups compared with the control group (p < 0.040). Change in quality of life-physical function was significantly associated with the change in symptom severity and muscle strength. No lymphedema exacerbations or other adverse events occurred during this trial.

CONCLUSION

Women with BCRL can safely lift heavy weights during upper body resistance exercise without fear of lymphedema exacerbation or increased symptom severity.

IMPLICATIONS FOR CANCER SURVIVORS

Women with breast cancer-related lymphedema can be informed that appropriately prescribed and supervised upper body resistance exercise is safe and can aid in the management of lymphedema through improvements in physical function and quality of life.

The prevalence of lymphedema symptoms among survivors of long-term cancer with or at risk for lower limb lymphedema

OBJECTIVE

The aim of this study was to identify commonly reported symptoms in the lower limbs among those with or at risk for developing lower limb lymphedema (LLL).

DESIGN

The authors surveyed survivors of long-term cancer using the Pennsylvania State Cancer Registry. They inquired about demographics, cancer treatment history, knowledge about LLL, and symptoms experienced since completing cancer treatment. They invited all participants for an in-person clinical assessment to better identify and characterize the symptoms associated with LLL.

RESULTS

The response rate to the study survey was 57.2%. Among the 107 participants who answered the study survey, 37 (34.5%) reported one or more symptoms associated with LLL. Many reported a combination of symptoms that included difficulty walking (n = 37; 100%), aching (n = 32; 86%), puffiness (n = 28; 76%), and pain (n = 27; 73%) on one side of the body since cancer treatment. The in-person clinical assessment among a subsample of 17 participants revealed 10 participants with no evidence of LLL and 5 and 2 participants with grade 1 and 2 LLL, respectively. The in-person clinical assessment identified three cases of previously undiagnosed LLL.

CONCLUSIONS

One third of the survivors of cancer surveyed reported experiencing new symptoms in the lower limbs since cancer treatment. Cases of symptomatic, undiagnosed LLL may exist in the population.

Best Practice Guidelines in Assessment, Risk Reduction, Management, and Surveillance for Post-Breast Cancer Lymphedema

Breast cancer-related lymphedema (LE) is a progressive, chronic disease that affects millions of cancer survivors and primarily results from surgical lymphatic vessel/node removal and radiation therapy. Patient education and support for importance of early detection is essential in helping health care providers detect lymphedema early, when there is the best chance to prevent progression. Improved imaging and surgical techniques have decreased the incidence of LE; however, effective risk-reduction and treatment have historically lacked the level of evidence necessary to standardize effective treatment. The purpose of this article is to report an extensive review of literature, including highlighted multidisciplinary studies within the past three years, in order to update best practice guidelines in assessment, risk reduction, management, and surveillance for post-breast cancer lymphedema.

Lifestyle risk factors associated with arm swelling among women with breast cancer

BACKGROUND

Breast cancer-related lymphedema (BCRL) is a feared complication for breast cancer patients who have undergone axillary surgery. Although clinical risk factors for BCRL are defined, data are sparse regarding common exposures that might induce incident arm swelling. The goal of this study was to quantify the association between common exposures thought to be potential risk factors and the occurrence of incident arm swelling among breast cancer survivors with or at risk for BCRL.

METHODS

This is a prospective subanalysis of the Physical Activity and Lymphedema (PAL) trial, a randomized controlled trial of 295 breast cancer survivors. Participants reported their exposure to 30 different potential risk factors at 3 month intervals for 1 year. Incident arm swelling was defined as a ≥5% increase in interlimb water volume difference between two consecutive time points.

RESULTS

Twenty-seven participants (9%) experienced incident arm swelling and 268 patients (91%) did not. Sauna use was the only exposure that was significantly predictive of incident arm swelling (p = 0.05). Nonwhite and nonblack participants had a significantly increased risk for experiencing incident arm swelling (p = 0.005 for both comparisons).

CONCLUSIONS

In our patient cohort, many common exposures that have been reported to be risk factors did not prove to have a significant predictive relationship for incident arm swelling. This study supports the recommendation that breast cancer patients who have had axillary surgery should avoid sauna use. The results do not confirm the need for other restrictions that may interfere with the quality of life in women with breast cancer.

Neither Heavy nor Light Load Resistance Exercise Acutely Exacerbates Lymphedema in Breast Cancer Survivor

Resistance exercise has great potential to aid in the management of breast cancer–related lymphedema (BCRL), but little is known regarding the acute response of performing resistance exercises with the affected limb. Purpose. To examine the acute impact of upper body resistance exercise on the amount of swelling and severity of symptoms in women with BCRL and to compare these effects between resistance exercise involving high and low loads (heavier vs lighter weights). Methods. Seventeen women aged 61 ± 9 years with mild to severe BCRL participated in this study. Participants completed a high load (6-8 repetition maximum) and low load (15-20 repetition maximum) exercise session consisting of 2 sets of 5 upper body resistance exercises in a randomized order separated by a 10- to 12-day wash-out period. The extent of swelling was assessed using bioimpedance spectroscopy, dual-energy x-ray absorptiometry, and arm circumference measurements. The severity symptoms were assessed using the visual analogue scale (pain, heaviness, and tightness) and a modified Brief Pain Inventory. Measurements were taken pre-exercise, immediately post-exercise, 24 hours post-exercise, and 72 hours post-exercise. Results. No changes in the extent of swelling or the severity of symptoms were observed between pre-exercise and immediately post-exercise, 24 hours post-exercise, or 72 hours post-exercise. No differences in the response to the high or low load exercise were observed. Conclusions. Upper body resistance exercise does not acutely increase swelling or feelings of discomfort/pain, heaviness tightness in the affected limb of BCRL patients when performed at either high or low loads.

The 2011-2016 Transdisciplinary Research on Energetics and Cancer (TREC) initiative: rationale and design

PURPOSE

Recognition of the complex, multidimensional relationship between excess adiposity and cancer control outcomes has motivated the scientific community to seek new research models and paradigms.

METHODS

The National Cancer Institute developed an innovative concept to establish a center grant mechanism in nutrition, energetics, and physical activity, referred to as the Transdisciplinary Research on Energetics and Cancer (TREC) Initiative. This paper gives an overview of the 2011-2016 TREC Collaborative Network and the 15 research projects being conducted at the centers.

RESULTS

Four academic institutions were awarded TREC center grants in 2011: Harvard University, University of California San Diego, University of Pennsylvania, and Washington University in St. Louis. The Fred Hutchinson Cancer Research Center is the Coordination Center. The TREC research portfolio includes three animal studies, three cohort studies, four randomized clinical trials, one cross-sectional study, and two modeling studies. Disciplines represented by TREC investigators include basic science, endocrinology, epidemiology, biostatistics, behavior, medicine, nutrition, physical activity, genetics, engineering, health economics, and computer science. Approximately 41,000 participants will be involved in these studies, including children, healthy adults, and breast and prostate cancer survivors. Outcomes include biomarkers of cancer risk, changes in weight and physical activity, persistent adverse treatment effects (e.g., lymphedema, urinary and sexual function), and breast and prostate cancer mortality.

CONCLUSION

The NIH Science of Team Science group will evaluate the value added by this collaborative science. However, the most important outcome will be whether this transdisciplinary initiative improves the health of Americans at risk of cancer as well as cancer survivors.

Trends in risk reduction practices for the prevention of lymphedema in the first 12 months after breast cancer surgery

BACKGROUND

Lymphedema is a feared complication of breast cancer surgery. We evaluated the trends in lymphedema development, patient worry, and risk reduction behaviors.

STUDY DESIGN

We prospectively enrolled 120 women undergoing sentinel node biopsy (SLNB) or axillary node dissection (ALND) for breast cancer and assessed lymphedema by upper extremity volume preoperatively and at 6 and 12 months postoperatively. We defined lymphedema as a >10% volume change from baseline relative to the contralateral upper extremity. Patients completed a validated instrument evaluating lymphedema worry and risk reducing behaviors. Associations were determined by Fisher's exact and signed rank tests.

RESULTS

At 6 months, lymphedema was similar between ALND and SLNB patients (p = 0.22), but was higher in ALND women at 12 months (19% vs 3%, p = 0.005). A clear relationship exists between relative change in upper extremity volume at 6 and 12 months (Kendall tau coefficient 0.504, p < 0.001). Among the women with 0 to 9% volume change at 6 months, 22% had progressive swelling, and 18% resolved their volume changes at 12 months. Overall, 75% of ALND and 50% of SLNB patients had persistent worry about lymphedema at follow-up, and no difference existed in the number of risk reducing behaviors practiced among the 2 groups (p > 0.34).

CONCLUSIONS

Upper extremity volumes fluctuate, and there is a period of latency before development of lymphedema. Despite the low risk of lymphedema after SLNB, most women worry about lymphedema and practice risk reducing behaviors. Additional study into early upper extremity volume changes is warranted to allay the fears of most women and better predict which women will progress to lymphedema.

Comparison of tai chi vs. strength training for fall prevention among female cancer survivors: study protocol for the GET FIT trial

Background

Women with cancer are significantly more likely to fall than women without cancer placing them at higher risk of fall-related fractures, other injuries and disability. Currently, no evidence-based fall prevention strategies exist that specifically target female cancer survivors. The purpose of the GET FIT (Group Exercise Training for Functional Improvement after Treatment) trial is to compare the efficacy of two distinct types of exercise, tai chi versus strength training, to prevent falls in women who have completed treatment for cancer. The specific aims of this study are to: 1) Determine and compare the efficacy of both tai chi training and strength training to reduce falls in older female cancer survivors, 2) Determine the mechanism(s) by which tai chi and strength training each reduces falls and, 3) Determine whether or not the benefits of each intervention last after structured training stops.

Methods/Design

We will conduct a three-group, single-blind, parallel design, randomized controlled trial in women, aged 50–75 years old, who have completed chemotherapy for cancer comparing 1) tai chi 2) strength training and 3) a placebo control group of seated stretching exercise. Women will participate in supervised study programs twice per week for six months and will be followed for an additional six months after formal training stops. The primary outcome in this study is falls, which will be prospectively tracked by monthly self-report. Secondary outcomes are maximal leg strength measured by isokinetic dynamometry, postural stability measured by computerized dynamic posturography and physical function measured by the Physical Performance Battery, all measured at baseline, 3, 6 and 12 months. The sample for this trial (N=429, assuming 25% attrition) will provide adequate statistical power to detect at least a 47% reduction in the fall rate over 1 year by being in either of the 2 exercise groups versus the control group.

Discussion

The GET FIT trial will provide important new knowledge about preventing falls using accessible and implementable exercise interventions for women following chemotherapy for cancer. ClinicalTrials.gov NCT01635413

Randomised controlled trial to determine the benefit of daily home-based exercise in addition to self-care in the management of breast cancer-related lymphoedema: a feasibility study

Exercise is considered to be a key aspect of lymphoedema treatment, although there is little evidence for the therapeutic effect of exercise in managing breast cancer-related lymphoedema (BCRL). This small randomised controlled trial (RCT) was designed to determine the feasibility, prior to undertaking a larger RCT, of researching a daily home-based exercise programme to treat stable BCRL. An experimental design compared the exercise intervention combined with standard lymphoedema self-care to self-care alone over a 6-month period. Twenty-three women with stable unilateral BCRL of ≥10 % excess limb volume (ELV) were randomly allocated to a daily home-based exercise programme and self-care (n = 11) or self-care measures alone (n = 12). The primary objective was to determine difference in limb volume reduction for the two groups. Secondary objectives were to monitor change in other areas that impact BCRL: quality of life, arm function and range of shoulder movement. All 23 women completed the trial, providing full data for each time point. The intervention group showed a clinically and statistically significant improvement in relative ELV at week 26 (95 % confidence interval (CI) -26.57 to -5.12), whereas the control group improvement crossed the line of no effect (95 %CI -17.71 to 1.1). This study demonstrated the feasibility of conducting a RCT of exercise as a therapeutic intervention in the management of BCRL. Although the sample was small, the results support the findings of other exercise studies which have shown trends towards improvement.

Update on the biology and treatment of lymphedema

OPINION STATEMENT

The past decade has produced an explosion of insights into lymphatic vascular development and structural biology and, in parallel, into the function of the lymphatics in health and in disease. In lymphedema, there is a spectrum that extends from primary (heritable) to acquired causes of disease. The diagnosis of lymphatic edema implicates a very specific treatment approach that is predicated upon the favorable impact of physiotherapy upon lymph flow and protein clearance from the edematous zones of the body. The recognition of the unique biology that accompanies lymphatic causes of edema has stimulated new research directions that are likely to translate into exciting new pharmacologic and molecular approaches to diagnosis and treatment.