- Exercise is safe provided that individual limitations and side effects are considered and monitored
- Health-related physical activity guidelines for the general population are appropriate for most people after a diagnosis of breast cancer
- Healthcare professionals can help provide information on the benefits of exercise for people with a breast cancer diagnosis
Breast cancer is the most common cancer in the UK with survival from the disease continuing to improve.1 More than eight out of 10 women survive breast cancer beyond five years.1
Many people with breast cancer choose to modify their lifestyles to improve their chances of staying well. The influence of lifestyle on breast cancer risk has been extensively researched and reported on. The main focus has been on which lifestyle factors affect a healthy person’s risk of developing breast cancer for the first time. More recently, studies have investigated whether lifestyle affects the risk of recurrence and death in people who have already been diagnosed with breast cancer. This article will outline the evidence for the benefits of exercise in women who have been diagnosed with breast cancer. There is currently insufficient data on the effects of modifying lifestyle on the risk of breast cancer recurrence and death among men with breast cancer.
The precise mechanisms through which physical activity may influence cancer recurrence and mortality have not been established, but areas of ongoing research include the role of adiposity, metabolic and sex hormones, growth factors, immunological processes and chronic inflammation.
Exercise and risk of recurrence/death after breast cancer
Any information given to patients about the beneficial effects of exercise on reducing the risk of recurrence and death should be placed in the broader context of other more significant risk factors for recurrence, such as the type and stage of the breast cancer.
There is increasing evidence of a link between exercise and improved survival after breast cancer. One study2 found the greatest benefit was in women who performed the equivalent of walking for three to five hours per week at an average pace. Another3 also suggests that two to three hours per week of moderate-intensity physical activity (such as brisk walking or cycling) is associated with an approximately 25% reduced risk of death (all-cause and breast cancer). Reduced overall mortality and mortality from breast cancer among women who engage in physical activity after a breast cancer diagnosis is further supported in a population-based prospective study.4
Additionally a meta-analysis5 provides evidence for an inverse relationship between exercise and mortality in patients with breast cancer and supports the notion that exercise should be incorporated into daily routines by breast cancer survivors. A more recent meta-analysis6 also reports exercise is associated with reduced breast cancer-specific mortality and all-cause mortality, with a stronger mortality reduction among overweight women than normal weight women and among postmenopausal women than premenopausal women.
Exercise and fatigue
Previously cancer patients were often advised to rest and reduce their daily activities to avoid or improve fatigue. Although patients suffering from fatigue might have difficulty believing that exercise will improve their symptoms, there is evidence that taking part in physical activity can increase functional capacity and decrease the sense of fatigue.
Studies looking at the effect of exercise on cancer-related fatigue vary in the type of activity and the duration of any specific programmes. Some have used a prescribed and supervised type of activity while others are based on patient choice and are unsupervised. Regardless of these limitations, all trials have demonstrated significant benefits (less fatigue and emotional distress, decreased sleep disturbance, improved functional capacity, and better quality of life) of moderate exercise in patients with cancer. A Cochrane review7 of fatigue data from 56 randomised trials of patients with cancer-related fatigue concluded that exercise was significantly more effective than the control intervention regardless of whether it was delivered during or after adjuvant therapy, and that fatigue was significantly reduced.
Exercise and lymphoedema
Surgery for invasive breast cancer involves removing a sample or all of the axillary lymph nodes. Some people may be recommended radiotherapy to the nodes. This means there is a risk of developing lymphoedema over the course of a lifetime. Although limb exercise with weights and/or resistance devices is not recommended during the immediate recovery phase after lymph node surgery and/or radiotherapy, exercises to restore the full range of motion of arm and shoulder are recommended. In addition there is now accumulating evidence to suggest that exercise is safe including rowing, tennis and golf and resistance type activity which was previously considered detrimental to both the risk of developing lymphoedema and in those with established lymphoedema.
Recent National Institute for Health and Care Excellence (NICE) guidelines8 based on current best evidence state there is no indication that exercise prevents, causes or worsens lymphoedema in those who have or who are at risk of breast cancer-related lymphoedema. They also state exercise may improve quality of life.
Exercise regimes should ideally be developed in conjunction with a lymphoedema specialist and tailored to the individual, with any other existing health conditions taken into account.9 A properly fitted compression garment should be worn when undertaking any exercise if lymphoedema is present.
What kind of exercise and how much?
There is no clear consensus or standard approach in the UK when it comes to exercise for breast cancer patients.
This is mainly due to the wide spectrum of patients in terms of age, ability, stage of disease and co-morbidities. Because of this, it seems unfeasible to have a standard approach for every patient. In addition the prior functional status and exercise habits of each patient should be taken into account when any activity is being considered. For example those with bone metastases, lyphoedema or existing co-morbidities should consult with their treatment team about a suitable activity.
However, health-related physical activity guidelines for the general population are appropriate for most cancer survivors. For those with cancer complications or co-morbidities that prohibit moderate-intensity exercise, avoidance of activity is advised. The Department of Health physical activity recommendations10 are thought reasonable for cancer survivors. These recommend 150 minutes per week of moderate-intensity activity (for example 30 minutes a day on 5 or more days of the week). But even a more modest amount of exercise will be beneficial compared to doing none. In addition, the British Association of Sport and Exercise Sciences (BASES) statement on exercise and cancer survivorship11 supports this advice.
Physical activity doesn’t have to be formal exercise. Any activity that makes people feel warmer and breathe more deeply, like a brisk walk, is acceptable. To optimise adherence the patient should choose the best exercise that can be adapted to his or her routine.
People should be advised to increase the amount of activity slowly if they are not used to exercising. Breast Cancer Care has developed a new walking initiative for people who have had a breast cancer diagnosis called Best Foot Forward.12
Conclusion and take home messages
Healthcare professionals can help raise awareness of and provide information on the benefits of exercise for people who have had a diagnosis of breast cancer.
There is increasing evidence that regular exercise after a diagnosis of breast cancer can have a substantial positive effect on mortality risk, morbidity, prognosis and quality of life.
The following points are taken from the BASES expert statement:11
- There is consistent evidence confirming that exercise can be safely performed during and after cancer treatment, provided that individual limitations and specific side effects associated with cancer therapies are considered and monitored.
- Based on research in survivors of the most common cancers, improvements in aerobic and muscular fitness, quality of life and fatigue can be expected through exercise training.
- Unless advised otherwise, cancer survivors should follow the health-related physical activity guidelines provided for the general UK population.
All cancer survivors including those with existing disease or who are undergoing difficult treatments should be encouraged, as a minimum, to avoid being sedentary.
There is currently no evidence that physical activity harms people who have had breast cancer and overall health benefits are proven.13 Exercise can also reduce the risk of other serious illnesses, especially important because breast cancer survivors have an elevated incidence of heart failure, coronary heart disease and osteoporosis (attributable to lifestyle and/or cancer treatments).14
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5. Ibrahim E, Al-Homaidh A. Physical activity and survival after breast cancer diagnosis: meta-analysis of published studies Medical Oncology 2011;28(3)753-65.
6. Zhong S, Jiang T, Ma T, Zhang X, Tang J, Chen W, Lv M, Zhao J. Association between physical activity and mortality in breast cancer: a meta-analysis of cohort studies. European Journal of Epidemiology 2014(6):391-404.
7. Cramp F, Byron-Daniel J Exercise for the management of cancer-related fatigue in adults. Cochrane Database Systematic Review 2012;11:CD006145.
9. Chang C and Cormier J Lymphoedema interventions: Exercise, surgery, and compression devices. Seminars in Oncology Nursing 2013;29(1):
13. Carmichael A. Physical activity as an adjuvant treatment for breast cancer; is it time for guidelines? European Journal of Surgical Oncology 2014;40(2):137-9.
14. Khan NF, Mant D, Carpenter L, Forman D and Rose P. Long-term health outcomes in a British cohort of breast, colorectal and prostate cancer survivors: a database study. British Journal of Cancer 2011;105(Supplement 1)S29-S37.
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