A growing body of evidence supports the importance of resistance training for building strength and improving functional outcomes in breast cancer survivors (1). Despite these benefits, many breast cancer survivors avoid upper-body activities, including resistance training, due to inaccurate advice regarding arm use, fear of lymphedema and perceived health risks related to performing upper-body exercise (2). In addition, breast cancer treatments, including surgery, radiation and lymph node removal, can cause swelling, weakness and pain in the arm, making resistance training more challenging to perform (3). Therefore, health and exercise professionals need to consider these challenges and make evidence-based decisions when designing resistance training programs for breast cancer survivors.

 Is Upper-body Resistance Training Safe?

Lymphedema is a condition that may occur following cancer treatment and is a major concern for many breast cancer survivors. It is characterized by swelling, pain and discomfort in the arm, which can limit range of motion, negatively affect arm function and increase the risk for infections (4). Previous healthcare guidance regarding lymphedema management recommended avoiding vigorous and repetitive arm exercise since it was believed that it could increase lymph production, and thus cause or exacerbate symptoms of lymphedema (5). However, research conducted over the last 20 years has shown just the opposite: upper-body resistance training does not increase the risk for developing lymphedema or exacerbate symptoms (6). In fact, there is evidence that supports positive effects from resistance training, including reduced arm swelling and overall improvement in lymphedema symptoms (7,8). Therefore, current research suggests that engagement in upper-body resistance training is safe for breast cancer survivors, and it may play an important role in the treatment and management of lymphedema.

In addition to being safe, resistance training can be an effective strategy to aid recovery following cancer treatment. Accelerated losses in muscle mass, strength and physical function, along with increased fatigue, are common side effects of breast cancer treatment (9–11). These side effects can persist for years following treatment and negatively affect overall quality of life. Breast cancer survivors who engage in resistance training can mitigate these negative changes and experience improvements in muscle mass, strength, physical function and quality of life, along with reduced cancer-related fatigue (12–14). Furthermore, upper-body resistance training can counteract surgery-related shoulder and arm impairments by increasing upper-body function and reducing arm pain and disability (15).

  Special Considerations for Program Design

Although upper-body resistance training is safe and can provide numerous benefits for breast cancer survivors, consideration for breast cancer–specific symptoms and treatment-related concerns should be made during exercise program design. Here are a few key considerations:

 - Arm symptoms: Breast cancer survivors are susceptible to arm pain, weakness, decreased range of motion and lymphedema. Therefore, start with low resistance, repetitions, sets, duration and frequency. Gradually progress while monitoring symptoms and adjust accordingly, reducing intensity if symptoms arise. Encourage breast cancer survivors who have been diagnosed with lymphedema to wear compression sleeves while exercising.

 - Cancer-related fatigue: Cancer-related fatigue is common and can interfere with the ability to engage in exercise, physical activity and activities of daily living. Monitor fatigue levels with each training session and modify the intensity, repetitions, sets or difficulty of the exercises as needed.

 - Peripheral neuropathy: Peripheral neuropathy is a side effect of chemotherapy that can lead to numbness in the hand and foot, muscle weakness and loss of balance (16). Encourage breast cancer survivors with peripheral neuropathy to perform upper-body resistance exercises in a seated position or perform standing exercises close to a chair or wall for support if needed. Wrist weights can also be used if peripheral neuropathy interferes with the ability to hold hand weights.

 - Longer warm-up may be needed: A longer warm-up with dynamic movement may be necessary to gradually increase range of motion, especially in the upper body.

 - Provide education: If your client is cautious about engaging in upper-body exercise training, provide information on the safety and benefits of upper-body resistance training for breast cancer survivors. Discuss strategies that will be used to maintain safety and minimize health risks and emphasize that the program will start at a low intensity with gradual progressions, while monitoring arm symptoms and fatigue. 

 In addition to the special considerations above, working with cancer patients or survivors requires specific knowledge and expertise. Therefore, if you are looking to expand your education and skills, you can become a Cancer Exercise Specialist through ACE. 

  References

1.       Campbell KL, Winters-Stone KM, Wiskemann J, May AM, Schwartz AL, Courneya KS, et al. Exercise guidelines for cancer survivors: Consensus statement from International Multidisciplinary Roundtable. Med Sci Sports Exerc. 2019;51(11):2375–90.

2.       Lee TS, Kilbreath SL, Sullivan G, Refshauge KM, Beith JM, Harris LM. Factors that affect intention to avoid strenuous arm activity after breast cancer surgery. Oncol Nurs Forum. 2009;36(4):454–62.

3.       Warmuth MA, Bowen G, Prosnitz LR, Chu L, Broadwater G, Peterson B, et al. Complications of axillary lymph node dissection for carcinoma of the breast: A report based on a patient survey. Cancer. 1998;83(7):1362–8.

4.       Sakorafas GH, Peros G, Cataliotti L, Vlastos G. Lymphedema following axillary lymph node dissection for breast cancer. Surg Oncol. 2006;15(3):153–65.

5.       Petrek JA, Pressman PI, Smith RA. Lymphedema: current issues in research and management. CA Cancer J Clin. 2000;50(5):292–307.

6.       Wanchai A, Armer JM. Effects of weight-lifting or resistance exercise on breast cancer-related lymphedema: A systematic review. Int J Nurs Sci. 2019;6(1):92–8.

7.       Schmitz KH, Ahmed RL, Troxel A, Cheville A, Smith R, Lewis-Grant L, et al. Weight lifting in women with breast-cancer-related lymphedema. N Engl J Med. 2009;361(7):664–73.

8.       Kim DS, Sim YJ, Jeong HJ, Kim GC. Effect of active resistive exercise on breast cancer-related lymphedema: A randomized controlled trial. Arch Phys Med Rehabil [Internet]. 2010;91(12):1844–8. Available from: http://dx.doi.org/10.1016/j.apmr.2010.09.008

9.       Sehl M, Lu X, Silliman R, Ganz PA. Decline in physical functioning in first two years after breast cancer diagnosis predicts 10 year survival in older women. J Cancer Surviv. 2013;7(1):20–31.

10.     Simonavice E, Liu P-Y, Ilich JZ, Kim J-S, Panton LB. Body composition, muscular strength, and physical function in breast cancer survivors. Int J Body Compos Res. 2011;9(2):57–64.

11.     Stasi R, Abriani L, Beccaglia P, Terzoli E, Amadori S. Cancer-related fatigue: Evolving concepts in evaluation and treatment. Cancer. 2003;98(9):1786–801.

12.     Hagstrom AD, Marshall PWM, Lonsdale C, Cheema BS, Fiatarone Singh MA, Green S. Resistance training improves fatigue and quality of life in previously sedentary breast cancer survivors: A randomised controlled trial. Eur J Cancer Care (Engl). 2016;25(5):784–94.

13.     Schmitz KH, Ahmed RL, Hannan PJ, Yee D. Safety and efficacy of weight training in recent breast cancer survivors to alter body composition, insulin, and insulin-like growth factor axis proteins. Cancer Epidemiol Biomarkers Prev. 2005;14(7):1672–80.

14.     Strasser B, Steindorf K, Wiskemann J, Ulrich CM. Impact of resistance training in cancer survivors: A meta-analysis. Med Sci Sport Exerc. 2013;45(11):2080–90.

15.     Do JH, Kim W, Cho YK, Lee J, Song EJ, Chun YM, et al. Effects of resistance exercises and complex decongestive therapy on arm function and muscular strength in breast cancer related lymphedema. Lymphology. 2015;48(4):184–96.

16.     Wickham R. Chemotherapy-induced peripheral neuropathy: A review and implications for oncology nursing practice. Clin J Oncol Nurs. 2007;11(3):361.