Aerobic Component

The aerobic component is a vital element of one's rehabilitation. In general, you should try to include a 20 to 30 minute aerobic activity into your daily activities. If to0 difficult, break a walk, for example, into two 10 minute phases, one in the morning and one at night. In addition to a stand alone aerobic component, an aerobic activity serves as a warmup to a more complete exercise session including strength and flexibility. In this context, the aerobic phase serves three functions: as a warmup, cardiorespiratory fitness and weight management. (Note that for some, losing weight may not be advisable but rather maintenance of, or gain weight may be advised.) The type of exercise chosen depends on your fitness level and the one you like to do. One of my favorite sayings is. "The best exercise is the one you'll do." Implicit in that is doing it consistently. Therefore, if you like to walk, that is the best one, if you like to swim, that is the one. Others include biking and a variety of aerobic machines such as rowing machine or an elliptical trainer. An advantage of using whole body machines such as an elliptical trainer or rowing machine is that in addition to elevating your heart rate, you are also warming up many major muscle groups in both the upper and lower body.

Warmup

The warmup prepares the body for the exercise that follows and is composed of both general and specific components. The general warmup incorporates a 1o-15 minute cardiorespiratory activity such as treadmill, cycling, elliptical trainer, followed by general stretching of major muscle groups of the body, particularly those of the shoulder, back and abdominal areas. The is followed by a warmup that is more activity specific and involves stretching of the specifc muscle groups that you will be using and followed by light sets of the first exercise of the activity you'll perform. This will help you practice the movement to follow thereby increasing your efficiency with heavier weights.

Exercise Prescription: Introduction

The following exercise prescription is a menu of options specific to the needs of breast cancer. The exercises will be broken down into three general phases: the aerobic phase, flexibility, strength building or maintenance. These will be followed by a cool down. Exercise at your own level of tolerance. That means the length of time, how hard you do it and the number of times per week. That said, remember that while you don't want to overdo it, you must not underdo it. Gains are only made by stressing your system or systems,  albeit incrementally. 

Precautions

Neutropenia
Neutrophils are the most common type of white blood cell (WBC) and plays an important role in the defense against bacterial infections. (There are several kinds of white blood cells, including monocytes, lymphocytes, neutrophils, eosinophils, and basophils.) Neutropenia is a decrease in neutrophil cell counts in the blood and is a common side effect of chemotherapy for many forms of cancer, including breast cancer, lung cancer, lymphomas and leukemias. Neutropenia and a susceptibility to infection is a primary reason patients cannot adhere to their chemotherapy regimen. Neupogen and Neulasta are medications that stimulate the production of blood forming protein CSF thereby elevating WBC and have proved effective against it. In cases of neutropenia it may be wise to avoid public areas including an exercise center during the flu season and use anti-bacterial soap after using exercise equipment. Mild to moderate joint pain is a common side affect and one that may preclude weight bearing exercise.

Precautions

With physician approval regarding an adequate recovery from surgery, possible complications from any metastasis and your blood counts there are few precautions to take when exercising. However, the following may be helpful to those who may be concerned about the possibility of lymphedema and to those who have had breast reconstruction.

Lymphedema
Lymphedema is a swelling of the affected arm due to lymph channels becoming blocked often as a result of surgery, axillary lymph node dissection and radiation. While many women are justifiably concerned about lymphedema, high level vigorous and repetitive activity of the upper-extremity have been shown not lead to lymphedema (Physician and Sport Medicine, August, 2002). However, if the lymphatic channels are impaired due to treatment, caution may need to be taken with heavy weights as it may lead to inflammation with the lymphatic fluid backing up in the arm. (Sander T, PT, personal correspondence, December 9, 1999). The wearing of a compression sleeve during exercise is suggested. Similarly, if swelling occurs in the hands and wrist, try wearing spandex biking gloves. Also, when working in the garden hands and arms should be protected from infection with gloves and long sleeves.

Breast Reconstruction
For those with breast implants and living tissue reconstruction strength training can usually be resumed within 12 to 16 weeks. It is, however, particularly important that you check with your surgeon before beginning your program. To those who have had the TRAM flap procedure moderate abdominal exercises should only be performed. Heavy lifting such as small children, or heavy laundry should also be restricted for about three to four months. Swimming is particularly recommended. Remember to “walk tall” with your shoulders back.

Exercise Goals for Breast Cancer cont.

3. Correct Postural Imbalance
Just as many favor one arm to the detriment of the affected arm, many patients carry one's shoulder forward or carry the involved arm close to the body resulting in postural imbalance. This, in turn, further limits shoulder flexibility. Similarly the loss of a breast without reconstruction or prosthesis often results postural imbalance.

4. Weight Management
Weight gain frequently occurs as a result of hormonal therapy such as the use of tamoxifen, and inactivity and has been associated with the likelihood of recurrence and lymphedema.

5. Manage Hypercalcemia
Certain types of cancer, particularly lung and breast cancer, as well as some cancers of the blood, such as multiple myeloma, stimulate the release of calcium from bones into your blood. This is known as hypercalcemia Spread of cancer to the bones also increases the risk of hypercalcemia. Moderate weight bearing exercises like walking and moderate closed chain exercises such as free weights to maintain bone density is suggested.

Exercise Goals for Breast Cancer

In general, primary exercise goals for breast cancer rehabilitation include maintaining one's range of motion or flexibility in the shoulder area, maintaining or regaining one's strength and weight management.

1. Flexibility
A primary goal is to maintain or increase the range of motion around the shoulder joint. Tumor removal, axillary dissection and radiation often result in skin tightness, scarring and the all of which can affect range of motion in the shoulder area. Surgery such as a mastectomy and radiation can also result in frozen shoulder which is a tightening of the capsule around the shoulder due to shortening of the tendons and ligaments. This, in turn, can limit movement for extended periods which often compounds the problem.

2. Strength
A related goal is the maintenance of strength of strength around the shoulder joint and the arm. Unless, it is a radical mastectomy, loss of strength is generally due to lack of use resulting in the weakening of shoulder muscles and the shortening of connective tissue. Many women will, unfortunately, limit the use of the affected arm due to a fear of lymphedema (to be discussed in a later posting). The foregoing reduces the ability to perform many daily activities again resulting in decreased strength.

Breast Cancer

Breast cancer is the leading cancer for women but one with a high survival rate. It is also the cancer type that lends itself most directly to therapeutic exercise. Depending upon the diagnosis, treatment may involve a lumpectomy, a simple or modified radical mastectomy or on occasion a radical mastectomy. In these later cases many younger women may opt for breast reconstruction. During initial surgery, lymph nodes in the axilla or underarm area are often removed for staging purposes. The recent use of sentinal node biopsies reduce the need for the the removal of many lymph nodes thereby limiting scarring. Breast cancer may spread by seeding to adjacent areas or metastasize to adjacent areas to through the blood vessels and/or lymph vessels. The most common sites of distant metastasis for breast cancer are the bones, lungs, liver and occasionally the brain. Treatments commonly include radiation therapy, chemotherapy and hormone therapy such as tamoxifen with two or more methods often being used in combination.

Limitations to Exercise

Several factors need to be taken into account when prescribing exercise such as type of cancer, it's stage, grade and treatment strategy. For example, many breast cancers are diagnosed early with few limitations to exercise. Lung cancer, by contrast, is often diagnosed late with metastasis to the bones which limit the ability to exercise. It is also the prime organ for ventilation which compromises the ability to get oxygen to the exercising tissues. Accordingly, the goals of an exercise prescription should be largely guided by the limitations presented by the specific cancer. In such cases, the limitations to exercise of a certain cancer will be discussed prior to the goals and exercises.

Cancer Rehabilitation

Cancer rehabilitation refers to the prescriptive use of exercise to: 1. prevent the loss of physical function due to cancer or its treatment, 2. rehabilitate any loss of function that may have occurred due to cancer or its treatment 3. the maintenance of function due to cancer or its treatment, and 4. to minimize any loss of it due to cancer or its treatment. Underlying these goals is the ability for the patient to optimally perform daily tasks (ADL), as well as maintain quality of life (Q. of L). A safe exercise prescription should be assessment based, and as stated previously, physician approved. An assessment includes the type of cancer, stage of cancer, treatment strategy, where an individual is in recovery, as well as their goals. The prescription is therefore individualized to best meet the needs of the individual. An effective program will often also mediate psychological outcomes such such as a greater sense of control, reduced anxiety and depression.

More Than a Statistic Cont.

Compliance
Related to the above is treatment compliance. Some people just "give up", refuse treatment for their cancers, or do not alter there behavior. These people are entered into the database of patients and if they die earlier than patients that agree to therapy, they are still counted in the population prediction of survival. By refusing a treatment option such a chemotherapy an individual often will often affect their prognosis. This individual is still entered into the 5 year database.

Future Research
These estimates are based on data from thousands of cases of this type of cancer in the United States each year, but the actual risk for a particular individual may differ. It is not possible to tell a person how long he or she will live with a particular cancer. Because the survival statistics are measured in five-year (or sometimes one-year) intervals, they may not represent advances made in the treatment or diagnosis of this cancer.

I hope the above postings shed some light on being an individual rather than a statistic.

Adapted from an e-mail from Dr. Robert Bayer, oncologist at Delnor Community Hospital, Geneva, IL.

More Than a Statistic Cont.

Several factors need to be considered when discussing statistical averages versus possible outcomes for an individual. These include: comparing like cancers, variability in treatment, limitations of the 5 year time frame, compliance and future research.

Comparing Apples to Apples
When comparing outcomes you must compare cancers to "like" cancers and staging is disease specific. For example a stage I lymphoma of an indolent type (grows slowly) has a far better prognosis than a stage I resected lung cancer.

Variability in Treatment
Population based survival statistics are NOT comparable to the individual because of the variability in treatment and comorbities. Example, a stage 4 breast cancer that is of an indolent type that is treated with anti-estrogen therapy has a far higher survival than a stage 4 inflammatory breast cancer that is not hormone sensitive and is generally more rapid in metastasis

5 Year Limits
The whole issue of predicting "survival" is more social than scientific, in most of the medical literature. Funding for cancer research is usually not adequate to follow patients for "life" Patients move, change phones, change names, and change doctors so frequently that research studies tend to stop after 5 years, hence 5 year data limits. Ironically the "best" data on survival comes from actuarial life insurance databases. Research studies focus on "surrogate endpoints" or measures that are quicker and easier to get than survival. Example, time from cancer resection to relapse based on serial CT scans done at pre determined intervals. This is often called "Relapse Free Survival" and is a more common research endpoint.

More Than a Statistic

Following the pathology report and diagnosis, an individual may fall into a statistical category that may have a limited bearing on the prognosis at the individual level. For example, the report may indicate that the survival rate for an individual to live for 5 years is less than 10 percent. However, such cancer survival statistics, should be interpreted with caution. The following postings will look more closely at being a statistic or an individual, and how individual choices and promising research play a role in survival statistics.

Pathology Report

Much of the foregoing information is contained in the pathology report. Reports will vary according upon one's cancer, but generally contain demographic information, tissue removed and date. The description of the tissue removed for analysis will be either a "gross or macroscopic description" of the tissue or specimen visible to the naked eye and pertains to color, weight and size of tissue. The "microscopic description" which describes features seen under a microscope and includes features of the tumor such as a carcinoma and the cell of origin within that typology, as well as the grade and stage. Often information about tumor margins will be given. This refers to the presence of the tumor in the edges of the tumor that was surgically removed. If so, the margins are said to be "positive "or "involved. " If not, they are said to be "negative" or free of tumor. The presence of markers such as PSA or hormone receptors, e.g. estrogen positive may also be referred to. Based upon the foregoing, a final diagnosis will also be present.

A site I would recommend for understanding your specific pathology report is www.mybiopsy.org. This, in turn, will allow you to ask the right questions and choose correct treatment options.

Staging

Distinct from the grading scale that estimates a cancer's aggressiveness, staging estimates how much and where the cancer is located. Several classifications exist but most common is TNM. For most cancers, the stage is based on 3 main factors called the TNM method.

1. T-refers to the original (primary) tumor's size and whether or not the tumor has grown into other nearby areas.
2. N - refers to whether or not the cancer has spread to the nearby lymph nodes.
3. M-whether or not the cancer has spread to distant areas of the body.
   

The numbers are often translated into different stages including: in situ-abnormal but not invasive, and stages I, II, III, IV with subcategories. Usually the higher the number the more advanced the disease. Not all cancers are staged by the TNM method. For e.g., leukemias, are generally not staged in this way because they are already in the blood. Also, primary brain cancers that originate in the brain (primary cancers), tend to be localized and they are graded rather than staged.

Tumor Grading

Tumor grading, together with the stage of the tumor, assists doctors in planning treatment strategies. Tumor grading is an estimate of the tumor's malignancy and aggressiveness based on how the tumor cells appear under a microscope and the number of malignant characteristics they possess. Cancer cells are often undifferentiated and are termed primitive or anaplastic as they do not appear specialized like normal cells. There nuclei are also larger and irregular and there is also exhibit a large volume of dividing cells. While more than one scale is used depending upon the type of cancer, the following scale is commonly used:

• G1 Well-differentiated (Low-grade and less aggressive)

• G2 Moderately well-differentiated (Intermediate-grade and moderately aggressive)

• G3 Poorly differentiated (High-grade and moderately aggressive)

• G4 Undifferentiated (High-grade and aggressive)

Multiple Myeloma

Multiple myeloma is a cancer of the plasma cells. In multiple myeloma, abnormal myeloma cells divide repeatedly making more and more abnormal cells. These cells collect in multiple sites in the bone marrow and outer parts of the bones crowding out normal blood cells. This causes extensive destruction within the skeleton involving bones in the spine with consequent bone pain and fractures. Compressed vertebrae may put pressure on nerves causing more pain. The overproduction of plasma cells may crowd out the production of  red blood cells (RBC) thereby causing anemia.

Sarcomas

Sarcomas are a rare group of cancers that occur more commonly in children and rarely in adults. It is a cancer of the connective tissue or cells whose primary function is to hold or connect the body together. These sarcomas can be broken down into soft tissue sarcomas or tissues that connect, surround or support tissues or organs of the body including the nerves, fat, muscles tendons and blood tissues, and hard tissue sarcomas that affect the bone and cartilage. Primary bone cancer is rare with the most common type of bone cancer being osteosarcoma, which develops in new tissue in growing bones. Others include chondrosarcoma of cartilage tissue and Ewing's sarcoma in immature nerve tissue in bone marrow. Bone sarcomas occur more frequently in the extremities such as the arms and legs. 

Leukemia/lymphoma

Leukemia is a cancer of the organs that make blood: the bone marrow and the lymph system. The overabundance of white blood cells crowd the bone marrow and prevent it from producing enough red, white blood cells and clotting platelets. The body then loses its ability to fight infection, as well as increased possibility of anemia, easy bruising and bone pain. Leukemia may be acute which involves immature cells and half chronic with cells more advanced in development and tends to progress slowly. Leukemia represents approximately 5% of cancers and is generally associated with an older population. However, until recently childhood leukemia was the most common cancer of children. 

Lymphoma is a general term for cancers that develop in the lymphatic system affecting the body's immune system. There are two basic kinds of lymphoma, Hodgkin's which is a  unique kind of lymphoma and Non-Hodgkin's. The distinction between leukemia and lymphomas is somewhat arbitrary. If bone marrow involvement and circulating cells predominate or if they constitute the first recognized manifestation of the disease, the process is termed leukemia. Lymphomas originate in lymphoid tissues and rarely go into the blood stream.

Categories of Cancer, Carcinomas

As stated in previous post, cancer is not a monolithic disease but rather several hundred (albeit with often common pathways.) For our purposes they can be generally broken down into three major categories and further into hundreds of subtypes. The first two categories, carcinomas and sarcomas are solid tumors and leukemias and lymphomas are dispersed cells that may form a solid tumor.  The most common, carcinomas (from the Greek word crab due to often clawlike extensions) account for approximately 80-90 percent of all cases. Most carcinomas affect organs that secrete something such as the breast, the lungs (mucus) or pancreas. Most originate in the epithelium or sheets of cells that cover the surface area of affected tissue. The application of cancer rehabilitation to several specific cancers will be discussed in future entries.

Age

It is said that age is the single biggest risk factor for cancer and while one can get cancer at any age, the highest rate occurs in decades 6-8. This fits with the view that cancer is a multistep process  with genetic mutations or alterations in our DNA which involves going from a less malignant to a more malignant and invasive disease. The longer our exposure to carcinogens the longer we live, genetic mutations and tumors taking years to develop, and the ability of our immune systems to combat cancer as we age are thought to create these changes.

What is Cancer?

Cancer is not a single or monolithic disease but rather a group of 200 plus diseases characterized by uncontrolled growth of abnormal cells resulting in malignant tumors. Distinct from a benign or encapsulated tumor, malignant tumors possess the ability to penetrate tissues or organs, and move or metastasize to other sites. Depending on its stage, grade and site of origin, cancers have the ability to seed to an adjacent area called seeding or to metastasize from a primary to secondary or distant sites by the vascular or lymphatic systems. Later stage cancers may effect the functioning of vital organs, upset the body's metabolic process, or create obstructions.

"Ask Your Doctor About"

We can't avoid the caution "Ask your doctor about" associated with the daily barrage of pharmaceutical ads. Commercial interests aside, it is one caution that should absolutely be adhered to first when considering exercise as part of a recovery program. It is your oncologist who is aware of any contraindications to exercise relative to your type of cancer, its stage or side effects of one's treatment strategy. Indeed, the content of this blog is not designed to be a substitute for a medical consultation. In addition to your physician's advice, any therapeutic exercise program should be assessment based and guided by a health care or exercise professional who is trained in the field of cancer rehabilitation. 

Why this blog?

The Cancer Rehabilitation blog will address the role of therapeutic exercise in the rehabilitation of the cancer patient. We will begin with a brief overview of cancer, categories of cancer, as well as treatment strategies. More extensive treatment of these topics can be found in other sources including the websites of many cancer organizations.  I will, however, address what is not found in other sources, i.e, how prescriptive exercise can assist those currently in treatment  or post treatment, return to or maintain their physical (and psychological) function. More information may also be found on my website. Hope we all learn things from one another and I look forward to your questions and input.