Going to extremes
Not so long ago, a breast cancer patient who had lymph nodes removed was told to avoid using her arm for exercise of almost any kind, even mundane tasks like carrying groceries. The hope was to prevent lymphedema—a chronic, painful swelling caused by excessive fluid buildup that can limit wrist, elbow, and shoulder movement, as well as weaken grip strength and predispose the skin to infection. While inactivity was recommended in the past, there was never any evidence to back it up. Dr. Kaelin is challenging this dogma by studying female cancer survivors who row—one of the most stressful arm activities.
Up to 25 percent of patients who've had lymph nodes removed go on to develop lymphedema. Lymph fluid, part of the body's defense against infections, moves through arm tissues with the help of muscles contracting against the walls of the lymphatic channels. Eventually, the fluid makes its way back into the bloodstream to be refreshed. After the nodes and channels are removed, there may be too much fluid for the arm to process, causing a backlog of lymph fluid and swelling of the arm.
Yet, even though rowing is a rigorous, repetitious, and demanding arm exercise, none of the rowers in Dr. Kaelin's practice has lymphedema. The theory is that paced activity to build up arm strength and gradually stress the lymphatics widens the remaining channels to accommodate the increased flow of lymph fluid.
Another challenge to activity restrictions comes from new thinking about osteoporosis. "Obviously, not using your arm weakens upper body muscles and limits strength training, which is necessary to offset the bone loss of osteoporosis," says Dr. Kaelin. "Women who begin chemotherapy when they are premenopausal and enter premature menopause are at greatest risk for accelerated osteoporosis. They can lose as much as 7 percent of spine bone mass and 4 percent in the hip."
In her study, also funded by the Lance Armstrong Foundation, she is comparing arm symptoms of long-term breast cancer survivors (who are at risk for lymphedema) beginning a rowing program to those of healthy novice rowers. Arm symptoms and measurements of range of motion, arm circumference, and grip strength are recorded periodically. The trial is still recruiting participants, and it will be two years before all the information is gathered.
"We hope to clarify the role of exercise in recovery and in particular to demystify the response of the arm after surgery to exercise," says Dr. Kaelin.
Dr. Robinson adds, "The appeal of this study and others that members of the WCP are currently undertaking is that exercise and diet are nontoxic and relatively easy ways to aid recovery and prevention when compared to the side effects of treating a breast cancer recurrence. We've yet to prove this, but the scientific literature is beginning to show the value of both healthy eating and activity."
Recruiting for the insulin study is still in progress: Female breast cancer survivors interested
in participating should call Kristie Adloff, MPH, at (617) 632-5934.
To inquire about participation in the rowing study, contact Larry Raymond at (617) 732-8312.
