Exercise as it relates to Disease/Resistance exercises in the reduction of arm deficits following breast cancer surgery

This is an analysis of the journal article "Upper limb progressive resistance training and stretching exercises following surgery for early breast cancer: A randomised control trial" by Kilbreath et al., (2012).

What is the Background to this Research?

Prevalence

2012 statistics show that breast cancer is the most common cancer found among women. 16 000 new cases of breast cancer were estimated, equating to 12.3% of all new cancers diagnosed in 2016. Survivors often have many side effects as a result from life-saving treatments. This study aims to determine if a supervised exercise program reduces arm symptoms in women post breast cancer surgery. The treatments analysed in this paper include: a mastectomy, sentinel node biopsy, axillary node dissection and radiotherapy.

Breast Cancer Surgeries

Mastectomy:

• Partial/breast conservation surgery – Part of the breast tissue is removed
• Total – Removal of the whole breast 

Sentinel Node Biopsy (SNB):

SNB is the removal of the first lymph node under the armpit. This is the first place breast cancer is likely to spread if it grows out of the breast. If cancer cells are found in the sentinel node, further lymph node removal may need to occur.

Axillary Node Dissection (AND):

AND is the removal of several and possibly all the lymph nodes under the armpit. This surgery is performed if the cancer has spread into the lymph nodes. This reduces the likelihood of the cancer spreading to the blood stream and into other body parts.

Radiotherapy:

Radiotherapy is often a conjunct treatment to the above surgeries. Its aim is to reduce the probability of the cancer reoccurring in the breast, chest wall, armpit or lower neck. 

Women who undergo surgery for the treatment of breast cancer commonly experience side effects in the upper limbs. Symptoms can include pain, stiffness, swelling (lymphoedema), reduced strength and reduced range of motion (ROM). Lymphoedema is more likely to occur in SNB and AND surgery as the lymph nodes are removed. Symptoms can severely impair patient’s activities of daily living and quality of life. This can further correlate to psychological and co-morbidity side effects. 

The literature states that exercise is correlated with reduced arm symptoms post surgery and can help reduce many of the other side effects noted above. 

Where is the Research From?

All participants were randomly recruited from three metropolitan hospitals in Sydney, Australia and the Human Ethics Committee approved this study. This study was funded by Breast Cancer Australia.

What Kind of Research was this?

This study was a randomised control trial (RCT). A RCT is a study where the participants of the study are randomly allocated to receive an intervention within the study. In this study participants were allocated to an exercise group or a control group. The purpose of an RCT is to compare the outcomes of participants to determine if a particular intervention is responsible for the results in the study. RCTs sit high on the hierarchy of evidence as the process of randomisation helps eliminate bias from the study.

This study used a subjective self-reported questionnaire and a variety of objective measures to determine the effects of the exercise group. Having an objective measure allows the effects of the intervention to be quantified, which strengthens the validity of the study. Subjective measures alone are not enough in a study as self-reported measures tend to be overestimated. 

What did the Research Involve?

160 women with breast cancer who had undergone breast cancers surgery were randomly recruited and allocated into two groups. Randomisation ensures there is no significant characteristic differences between groups at the beginning of the study. This ensures the results can be attributed to the interventions, not differences between groups.

The intervention group

• 8-week exercise program
• Weekly exercise sessions; progressive resistance training and stretches for the shoulder
• Complemented with a home exercise program

The control group

• Seen fortnightly to assess their affected arm for the presence of lymphoedema
• No exercise or advice was provided

All participants received standard post-operative care offered by the hospital where they had surgery. They were provided handouts outlining arm exercises they had to perform, information regarding safety with heavy lifting and strategies to prevent lymphoedema.

The main outcome measure was a subjective scale relating to arm symptoms using the EORTC breast module where the participants rates their arm pain, swelling and difficulty elevating the arm on a scale of “not at all” to “very much”.

Physical measurements were completed by a blinded assessor and included:

• Shoulder ROM
• Shoulder strength
• Swelling
• Fluid measurements: to determine the quantity of lymph in the affected shoulder.

These measures were conducted immediately after the 8-week intervention and 6 months later. Blinding the assessor measuring the intervention strengthens the study by minimising bias for a particular intervention into the study.

What were the Basic Results?

There were no significant differences between groups for the self-reported arm symptoms immediately following intervention and at follow-up, however both groups reported reduced arm compared to baseline. There were no statistical significant differences between women based on the type of surgery they received for the treatment of their breast cancer. Shoulder ROM and strength were significantly greater in the exercise group immediately following intervention and was maintained at follow up. This was specific to shoulder flexion and abduction with range, with differences of 5 and 6 degrees respectively. The specific shoulder movements that had increased strength were shoulder abduction and horizontal abduction. 

Exercise did not result in any adverse effects during this study and there were no correlations between resistance exercise and the development of lymphoedema. This finding supports the use of low resistance exercise as a safe modality to increase shoulder function in women following breast cancer surgery.

What Conclusions can we Take From this Research?

Low resistance exercises and stretching increased shoulder range and strength but did not correlate to a reduction in arm related symptoms according to the EORTC-23 questionnaire. There were no side effects or resulting lymphoedema during this study so resistance exercise can be recommended as a safe modality for women following breast cancer surgery. Although the women in study did not report significant changes in arm symptoms during this study, exercise alone can improve many psychological and physical symptoms as identified in the literature and therefore should be recommended as adjunct treatment for women suffering from breast cancer. Further research on resistance exercise and cancer using high quality studies is needed to strengthen these findings.

Implications of the Research

Kilbreath et al, found that resistance exercise did not improve self-reported arm symptoms during this study. The authors did identify that this does contradict other high quality research that have shown that resistance and aerobic based exercise can improve a variety of symptoms in patients with breast cancer. This study along with the other supporting literature determines resistance based exercises to be a safe modality that can improve function, mood, fatigue and symptoms following breast cancer surgery.

Further reading

For more information on breast cancer surgeries and the effects of exercise for breast cancer patients, please see below:

• Types of breast cancer surgery: https://canceraustralia.gov.au/affected-cancer/cancer-types/breast-cancer/treatment/what-does-treatment-breast-cancer-involve/breast-cancer-surgery
• Exercise and breast cancer: https://www.bcna.org.au/media/2129/bcna_exercise_and_breast_cancer_booklet_0.pdf
• Breast cancer module – EORTC – B23: http://www.eortc.be/qol/files/SCManualQLQ-C30.pdf