Just Do It: Breast Cancer Survivors and Exercise

Following up on last week’s exercise post, I wanted to focus on two recent studies that really drive home the benefits of physical activity for breast cancer survivors. If you’re not exercising now, here’s why you should consider it.

In 2017, Hamer and Warner published a review in the Canadian Medical Association Journal (Open Access link here). They analyzed 67 existing studies in an effort to ascertain what lifestyle factors were most important in reducing the risk of breast cancer recurrence in survivors.

Whatever you can do right now is enough to start out with. Just keep moving!

The results were striking: of all the lifestyle variables that the researchers looked at, exercise came out on top. They found that engaging in moderate exercise resulted in a 40% decrease in cancer recurrence. This included easily-adoptable, low-cost programs such as brisk walking.

I want to stress: they weren’t talking about doing crazy-high amounts of exercise, but simply adhering to the current physical activity recommendations for US adults, which are as follows (summarized by the American Heart Association and taken from their website):

Sadly, only 13% of recent breast cancer survivors actually met those exercise guidelines, and that number dropped even more as time went on. Consider how that affects overall cancer rates, when we talk about our chances as survivors: if the vast majority of the population is not engaging in a beneficial habit, the reported recurrence rates will reflect that. However, if you do incorporate exercise into your life, one could argue that your chances of recurrence are significantly improved over the numbers usually cited.

In addition, an increase of at least 10% of body weight after breast cancer diagnosis, which unfortunately happens often, increased both risk of recurrence and mortality. Again, patients who exercised were able to avoid this weight gain, improving their chances for disease free survival.

Nonetheless, while it seemed relatively straightforward to achieve the percent reduction in recurrence, the researchers stressed two very important points: (1) this reduction came after finishing treatments, not in lieu of them, so one should not assume that exercise would necessarily take the place of conventional cancer treatments, and (2) sadly, some cancers will recur even if the survivor is doing everything “right” and so if there is a recurrence, it should not be taken as the individual not doing enough. That’s the cruel unfairness of cancer.

It’s never too late to start, but it’s never too early either! Pick a sport and make it yours!

The second study was original research with high-risk breast cancer patients by Cannioto et al. (2020), published in the Journal of the National Cancer Institute (Open Access link here). The study participants filled out a questionnaire about their exercise habits at four time points: (1) when they enrolled in the study after diagnosis (this question asked about pre-diagnosis exercise habits), (2) during chemotherapy, (3) one year after finishing treatment, and (4) two years after finishing treatment.

Once again, exercise was shown as having a significant impact: women who met the guidelines for physical activity (150 minutes/week of moderate exercise) before, during and after treatment had a 55% lower risk of recurrence and 68% lower risk of dying than those who didn’t meet the guidelines.

Even those who only started exercising after finishing treatment still had a significantly reduced risk of both recurrence and death compared to those who didn’t exercise at all. Additionally, benefits were also seen for those who consistently exercised, even if they didn’t fully meet the guidelines. So it seems that any exercise that these high-risk cancer survivors did was still better than not doing anything at all.

The same holds for you!

Both of these studies convey the importance of engaging in physical activity. Exercise is critical for the well-being of all humans, but even more so for breast cancer survivors. Think: when we receive a cancer diagnosis, we are ready to undergo potentially dangerous treatments, risking debilitating side effects that leave us bald, exhausted and wretched.

So why not engage in something as beneficial for body and spirit as moderate physical activity to help prevent the possibility of having to repeat the cancer treatment again?

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A few more bits of information:

The easy-to-read executive summary of the US Physical Activity Guidelines for Americans can be found here.

For a plain-language synopsis of the Hamer and Warner (2017) review, see this Healio interview with co-author Dr. Ellen Warner.

For a plain-language synopsis of the Cannioto et al. (2020) paper, see this article in breastcancer.org.

Tailor your exercise to your abilities…and then keep going!

Keep in mind that terms such as “moderate” and “intense” are relative to YOU. someone just starting out is not going to be able to handle the same level of intensity as a highly-trained individual, and there’s nothing wrong with that. Start where you are–it’s okay.

Finally, Dr. Robert Sallis, chairman of the American College of Sports Medicine’s Exercise Is Medicine inititative, has said, “If we had a pill that conferred the proven health benefits of exercise, physicians would prescribe it to every patient and healthcare systems would find a way to make sure every patient had access to this wonder drug.”

The two studies here show exactly why!

“The Gun Show”: Assessing Biceps Muscle Loss Due To Endocrine Therapy [PHOTOS]

In my last post, I whined about the repercussions of taking aromatase inhibitors (in my case, letrozole) as a way to diminish the amount of estrogen in my body, for the purpose of reducing the risk of breast cancer recurrence.

While I also mentioned letrozole’s effects on my exercise habits, in this post I wanted to drill down on one aspect in particular: muscle loss.

Before I go further, I need to add a disclaimer. Since the time the first photo was taken (the morning before my first chemo infusion), three and a half years passed and I went through menopause. Notably, the menopause was pharmaceutically-driven, starting with tamoxifen and then, after my hormone levels were low enough, continuing with letrozole. However, my body now is dealing with the same aging effects as someone who had transitioned naturally.

Except that my transition came before its time.

The below photo is from April 27, 2017, before I headed to the infusion center for my first dose of chemo. I had been training as normally as I could, under the conditions of lumpectomy and port placement that I wrote about here, and finding work-arounds for exercises that I’d been told not to do.

This is my 51-year-old biceps muscle, before I started the pharmaceutical portion of my breast cancer treatment.

While I lost some size and strength throughout my chemo infusions (here are all the photos), I was able to bounce back and had a particularly strong 2018 (sorry, don’t have good photos of that). But as the endocrine therapy with tamoxifen continued in 2019, to be replaced by letrozole in 2020, I could feel the effects of low estrogen.

On December 11, 2020, I struck the same pose again for sake of comparison.

Is something missing? This is my 54-year-old biceps muscle, struggling to keep up. Note: I am still working out as hard as I can!

As far as muscle appearance is concerned, I have experienced a slow downhill slide. My shoulder is not as peak-y, the biceps itself has decreased in size and I even find it more difficult to hold this muscular contraction. In addition, there’s more looseness in my skin, particularly at the back of my arm, which in part may be due to loss of collagen, also affected by estrogen levels (nice dermatological review by Shah & Maibach, 2001, Am J Clin Dermatol).

I’m busting my butt trying to increase the amount that I’m lifting, but I’m not making progress. Not surprisingly, the decrease in estrogen plays a role in this. As stated by Chidi-Ogbolu & Baar (2019, Front Physiol), “estrogen improves muscle mass and strength, and increases the collagen content of connective tissues”.

It makes sense then that lack of estrogen is going to be detrimental to maintaining muscle. To that point, Kitajima & Ono (2016, J Endocrinol), working with animal models, have found that “estrogen insufficiency leads to muscle atrophy and decreased muscle strength of female mice.”

Not just mice, obviously.

This information comes as no surprise to any woman who’s gone through menopause, I’m sure. But the experience of being slammed through menopause instead of having the opportunity to transition more gradually is yet another frustrating way that having cancer pulls the rug out from under you and reminds you that you are not in control of your life.

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Slowly, yoga is becoming more important in my life and my view of fitness is changing. Good thing too, since I can’t keep beating myself up like this.

How Mindfulness Helps with Exercise Motivation

Exercise has been an integral and indispensable part of my cancer recovery and my life as a whole. I’ve maintained a personal trainer certification (ACSM-CPT) for over a decade and even though I don’t train professionally, I keep abreast of new research and love a challenging workout.

Still, there are days that even I find myself dreading the session I have planned. For those times, I engage in mental calisthenics and rely on a mindful attitude. If you’re struggling to find motivation to exercise, this may help you too.

Note, motivation is something you generate yourself. It is inside you, but you have to coax it out. Be gentle. Hiring a personal trainer to beat you with a stick when you’re not up to a workout is not going to make you look forward to exercising more. But the following concepts might help:

Consider that a workout is made up of a series of movements.

Stop looking at a workout as a massive monolithic thing. Doing so can be overwhelming and make it more likely that you’ll talk yourself out of it before you even begin. Instead, consider that it’s made up of distinct parts, steps that you take one at a time.

Stay in the moment and keep each movement fresh.

Stay present and focus on the part of the movement that you’re doing at the moment, truly feeling into it. If you’re on a rowing machine, concentrate on each individual stroke making sure that you’re using proper form as you reach, push with your legs, and pull the handle. If you’re lifting weights, focus on where your body is in space, on contracting the muscle as you lift, on exhaling as you do so, keeping your body properly aligned. If your exercise is a brisk walk, be aware of how you’re stepping, pushing forward, swinging your arms. These movements become a meditation in and of themselves.

What matters is the here and now.

Release thoughts of how much longer you have until you’re done. Focus on the stroke, step or rep that you’re taking at this very moment. And then when you’ve completed it, consider the next movement with the same fresh attitude. Just as you would if you were focusing on each breath during meditation.

If you can’t finish your workout, that okay. You can try again tomorrow.

Practice self-care.

Do not force yourself to finish an entire workout if you *really* don’t have the energy to–but that means truly listening to your body’s limitations, not discouraging voices in your head. You are better off making a concerted effort at doing, say, half your distance or only one set per weight lifting exercise and doing it well, instead of making yourself so miserable that you don’t exercise again for another week and a half.

If you’re thinking, “I’m not up to doing the entire workout”, ask yourself, “Well, how much can I do?” and at least start. Consistency is key.

Let go of expectations.

Release preconceived notions of how your workout will go and how tired, miserable or sore you’ve already decided that you will feel. Look at each movement with fresh eyes. Employ a beginner’s mind. Get curious about how everything feels.

While it’s true that you’re exercising your body, your mind has a lot of influence on what will happen. The kind of exercise session you have is up to you. Decide to use your best form, draw on as much energy as you have in the moment, and exercise as much as you have planned. And if you cannot go as long you anticipated and have to stop earlier, let that be okay. No matter how much exercise you do, you are still better off than having done nothing. No one can take that accomplishment away from you.

And tomorrow, experience it anew again.

Invisible Effects: Body Image, Part 2

Oddly enough, one of the things that scared me about cancer was that it threatened all the work I’d put into my body. Being a bit under six feet tall since my teenage years, I was called “big” a lot whether or not I was overweight. At 16, I went through a phase of disordered eating. That passed, but I retained a sensitivity to how I was perceived by others. Always, I was fearful of being judged, and that pushed me towards perfectionism.

Fast-forward to 2017 and my diagnosis. When I started researching breast cancer, one thing that struck me was that the information I found didn’t mesh with my conception of what cancer was, in terms of what the treatment did to the patient. I had always thought of cancer treatment as having a wasting effect on the sufferer. But then I read of the propensity that many breast cancer patients had for putting on excess weight, not only throughout chemo, but also due to taking estradiol-blocking medications like Tamoxifen.

Wait, what? Gaining weight? But I’d always thought that cancer patients lost weight! Sure enough, google “breast cancer weight gain” and you get a lot of entries from reputable sources that warn about this tendency to pack on weight. My Nurse Navigator echoed that point, noting that many women “put on 10-15 pounds.”

Many decisions in my life have been motivated by a fear of being judged.

This provoked a lot of frustration. I had established excellent diet and fitness habits for the very purpose of building strength and endurance and avoiding the weight gain that accompanies advancing age. I had kept emotion out of my food choices (kudos to my mother for being careful about not connecting food and emotion). During my time as a stay-at-home-mom, I’d obtained a highly-respected personal trainer certification because I wanted to be sure I knew what I was talking about. My standards were high, but even if I couldn’t attain my version of “perfection”, I put in 100% effort and that made me feel good.

And then, cancer. Despite doing everything I could think of to maintain peak health, I still had not been able to prevent the development of my tumor. That was extremely unsettling. But for me, having my whole body shape change as a result of this was almost worse.

Predictions of the future raced through my mind: I was going to lose my lean mass, lose my fitness and put on ten or more pounds. I would be judged for “letting myself go”. None of this would be under my control. Just like the cancer, it was all happening to me, and as far as I was concerned it was bound to ruin my life, whether or not it actually killed me.

However, as with so many other things related to my cancer, this didn’t go the way statistics predicted. And that’s why there’s a Part 3 to this body image series…

This Is Your Arm On Drugs, Part II

While my previous post had focused on appearance, how I looked was a relatively small part of getting back to where I’d been physically. Much more important was the hit my strength and endurance levels took, and those don’t really show up in the photos I posted. While there’s not a huge change in muscle size, my strength did decrease significantly, not surprising given that I was going through cancer treatment. At the “height” of each chemo infusion, I had trouble walking, sometimes even lifting my head from the pillow. Movements required a lot of effort.

All that rest time affected my physical ability. I’d been told not to row (Concept2 erg) for four weeks after the lumpectomy on my left breast. That was tough because rowing is a form of meditation for me, the quintessential mindful movement — it was stress management that I desperately needed. I wanted to follow the rules so I stayed off the erg, but incorporated light weights into my “weenie” workouts. That helped, but I felt frustrated and weak.

Then, after those four weeks were almost over, I had my chemo port implanted on the right side of my chest wall, and again was told not to row for 3-4 weeks. Well, a week after port placement, I had my first infusion. ARGH! Sooooo, I wasn’t able to get back to rowing until I’d recovered from my first chemo.

My strength continued to increase after each of the first three infusions, which was gratifying. I’d gotten to about 2/3 of my pre-surgery strength training weight load. But after the 4th infusion, the fatigue started to catch up with me and I had to slow down. I was tired! To make matters worse, my bloodwork before the 5th infusion revealed an increase in the levels of two liver enzymes, ALT and AST. Chemo is hard on the liver, which works overtime to clear out the drugs from your system. If those numbers continued to go up, my 6th infusion would be delayed.

Now, you might think: what’s the big deal, waiting a week or two longer for the last infusion? Psychologically that would have been devastating. For me, getting through chemo was more than enduring its physical effects; the mental component was huge because of the stark contrast between my level of fitness previously compared to where cancer had knocked me down to. The dates of each infusion were seared into my mind, and I really needed chemo to be over.

My solution was to implement every means imaginable for decreasing liver enzyme levels. That included foregoing heavy lifting, according to my research. Anything, to finish on time. For the weeks before my last chemo, I was a green-tea-guzzling, dark-leafy-green-devouring, turmeric-supplement-popping, hyper-hydrated couch potato. Thankfully, my numbers went down and I finished chemo as scheduled.

The final infusion required the longest recovery. Once I got over the worst of the side effects, I could still only row 500 meters at a time at a harder pace, and my weight load and repetitions had dropped dramatically when strength training. While I was done with the hard chemo, I still had Herceptin infusions (and still had the port implanted, which got in the way) and those affected my heart, so I got tired more quickly. Not chemo-tired, but tired enough. I focused first on improving muscle endurance (lighter weights, higher reps) and then gradually increased the weight and dropped the reps to build muscle back.

There was a fire under my butt to get back to my version of “normal”. Ultimately, regaining strength was the easy part. The hard part was getting back to where I had been mentally, and even now I’m not sure I’m there yet. But who knows if I was in as good a state pre-diagnosis as I think I was?

My focus now is to train as hard as I can, stay as active as possible and not succumb to the weight gain that seems to afflict the average middle-ager. I guess I’m trying to find a “recipe” that will keep the cancer from coming back. It probably doesn’t exist, but seeking it is one way for me to maintain a semblance of control over something that is ultimately uncontrollable.

This Is Your Arm On Drugs, Part I

Chemo drugs, that is.

Say “chemo patient” and people think of a hairless, skeletal person who could be blown down by a gentle breeze. But is that really what happens?

I was anxious about how much chemo was going to ravage me, so I decided to document everything. That way when treatment was over, I would know how much work I had to do to rebuild myself. The simplest way for me to do this was to photograph my right biceps. The cancer was on my left side and I had not been using that arm as much, so the right arm would provide a more accurate view of what chemo treatment was doing to lean mass.

I hope you’ll forgive the following photos. It was never my intention to actually post these (or else I would have chosen a better background!). The cropping is a bit off and I’ve only now realized that even my biceps curl isn’t consistent throughout all the photos. In my defense, I was focused on getting through treatment, and worrying about getting the angles and lighting right was the last thing on my mind. All these pics were taken on the mornings of my infusion days.

Infusion 1 – 4/27/2017:

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Infusion 2 – 5/18/2017:

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Infusion 3 – 6/8/2017:

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Infusion 4 – 6/29/2017:

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Infusion 5 – 7/20/2017:

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Infusion 6 – 8/10/2017:

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Is there a difference? I think there is, even with the relatively crappy and inconsistent photos. I also think that hanging towels over the door makes the bathroom look messy. And, YEOW, I am mole-y!

Six courses of chemo (Taxotere and Carboplatin), one every three weeks, won’t destroy you, although the drugs do smack you around a lot. It would take about a week or so to recover following each infusion, at which point I could work out again. As the infusions went on, the recovery time increased.

So, no, my chemo regimen didn’t turn me into a skeleton, although my weight did take a hit; there were times that I was literally too tired to eat or my GI tract hadn’t fully recovered, making it tough to get food down. Because my infusions were spread out, I got a pretty hefty dose. But women whose cancer dictates weekly infusions, while possibly receiving smaller doses, don’t get the same amount of time to recover and the treatment effects build up. In that sense, I was very fortunate, and that made it possible to maintain my strength.

Once again, my worst fears weren’t realized. It took time to get back to feeling normal and training hard again, but I got there.

 

Lifting My Spirits

I received an unexpected but incredibly satisfying compliment today. It was from a worker at Trader Joe’s who made a flattering comment about my arms. A little background here: I like to work out, and even obtained a personal trainer certification when I was a stay-at-home-mom. While I’ve never trained people as a profession, I have maintained my certification over the years — in addition to a vigorous training schedule. I’ve been told that this is unusual for “a woman of my age”.

When I received my cancer diagnosis, I was shocked largely because in my mind my lifestyle didn’t seem to fit the profile of someone at high risk. One of my greatest fears as far as cancer was concerned was that it would affect my ability to train regularly. While so many people engage in eye-rolling when it comes to exercise — it’s popular to equate exercise with misery — having to take time off from working out was one of the most horrible outcomes I could imagine. My version of hell involves a sedentary existence. I train hard to enjoy my life, to be able to move and lift and not feel pain. I work out to live and that energizes me like nothing else. And anything that jeopardizes that is a death sentence to me.

Okay, maybe a little dramatic? But you get my point. I.Love.Exercise.

Today’s compliment was particularly poignant. During my 2017 doctor’s appointment to check out that suspicious lump in my breast, the doctor’s assistant commented that she wished she had my arms. I remembered that as I went through diagnostic tests and oncology visits and surgery. I followed my surgeon’s orders regarding not lifting heavy things (well, mostly, because “heavy” is negotiable), but as soon as that time limit passed, I was off and running. Exercise meant normality, and I craved feeling normal, as in “not sickly and dying from cancer”. There was mention of this nasty impediment to my life called lymphedema. I didn’t really think about it much until I was discussing lifting weights with my oncologist, who said, “Exactly HOW MUCH weight are we talking about here?” and sent me to the lymphedema specialists so that I wouldn’t go full-Schwartzenegger without knowing whether I was risking having my arm blow up. (It hasn’t so far.)

But my point: the compliment I received today made me feel like I’d come full circle. While, yeah, fear of death from cancer is a biggie, drastic changes to one’s lifestyle are also anxiety-provoking.

Today, I felt, I’m back.