The Breast Cancer Survivor's Fitness Plan: A Doctor-Approved Workout Plan For a Strong Body and Lifesaving Results (Harvard Medical School Guides)

The only breast cancer recovery program designed by a Harvard doctor and survivor and approved by the American Council on Exercise (ACE) Feel healthy again. Regain control of your life. Exciting new research reveals that regular exercise can reduce the chance of breast cancer recurrence and extend your life. Exercise can also help you recover energy, strength, and flexibility diminished by lifesaving breast cancer treatments. Dr. Carolyn Kaelin is a leading breast cancer surgeon who understands the important links among exercise, recovery, and the quality of life--and she is a breast cancer survivor, too. Designed with master trainers Josie Gardner and Joy Prouty, The Breast Cancer Survivor's Fitness Plan features effective, inspiring workouts tailored for each type of surgery and adapted for differing fitness levels. Feel strong again and Improve your flexibility and balance Rebuild your muscles Protect your bones Enhance your appearance, vitality, and all-around health For more information on Dr. Kaelin about breast cancer treatment and recovery, read her award-winning book Living Through Breast Cancer. (20060930)

Excerpt

CHAPTER 1

Taking Control

More than two million women living in the United States today have been treated for breast cancer, according to the American Cancer Society. Fortunately, we live at a time in medical history when increasingly sophisticated, lifesaving treatments are changing the course of this disease for hundreds of thousands of women. Just a handful of years ago, some of the most remarkable advances in surgery, radiation, and anticancer drugs were not yet widely available. Now, for most women, a breast cancer diagnosis may prove in hindsight to be a rough bump in the road, while the length of that road ultimately remains unchanged. For those living with metastatic breast cancer, an expanding list of treatments may be life-extending, also.

Yet whether breast cancer treatments have been tested over decades or emerge as new stars, they may take a heavy toll on a woman's body. "In barely a year, I've aged a decade," one breast cancer survivor succinctly reported, ticking off unwanted side effects of treatments that pile on pounds and weaken muscles and bones. Surgery to reconstruct the breast, which many women find life-enhancing, often presents additional challenges.

Now a growing body of research strongly suggests engaging in exercise reduces your risk for a recurrence and boosts the likelihood of living a longer, healthier life. What's more, a well-conceived, comprehensive exercise program can help you mini–mize or avoid many other concerns that arise after breast cancer treatments and reconstructive surgery.

No matter how uncomfortable or weak you might feel today, the simple, safe, and powerful program described in this book can help restore ease of movement and the strength and energy for daily tasks and pleasurable activities. Our goal is to enable you to rise to the joys and challenges each day brings. In essence, we hope to help you turn back the hands of a clock that spun forward far too quickly.

Laying the Foundation

Much of our program revolves around a series of progressive workouts. Yet safely and slowly stepping up your activities is only one part of your overall goal. Three other cornerstones of the program are a healthy diet, rest, and stress relief. What does this quartet have in common? Unlike so many aspects of breast cancer treatment, all four lie largely within your control. Together, they can significantly improve your health and the quality of your daily life. What's more, they can help you regain a sense of control over your own life that a cancer diagnosis so often undermines.

In the following sections, key facts and strategies are outlined. More in-depth information on paring off pounds, rebuilding muscle, and shoring up bones appears in Chapter 2.

Why Exercise?

In a nutshell, exercising regularly can help you:

• Optimize longevity. Being active cuts down the likelihood of breast cancer recurrence and boosts the odds of living longer. The long-term Nurses' Health Study surveys more than 120,000 female registered nurses about lifestyle factors and chronic diseases every two years. In 2005, researchers reporting on data drawn from nearly 3,000 study participants diagnosed with breast cancer found that those who engaged in even modest physical activity (such as walking for three to five hours over the course of a week) lessened the likelihood of recurrence and improved survival when compared with those who were sedentary or less active.

• Gain energy. One common concern stemming from breast cancer treatments is fatigue. Often, women report that their energy fluctuates day to day during treatment. Afterward, some women find energy returns fairly quickly, while others remain at low ebb for many months or longer. Slowly rebuilding endurance through easy cardiovascular exercise can help. According to the National Cancer Institute, some small, preliminary studies suggest that light to moderate walking or other activities may boost energy.

• Improve mobility. Discomforts that stem from mastectomy, lumpectomy, or lymph node surgery, radiation, and reconstructive surgery sometimes may be quite long-lasting, as Clara Walton can attest. Ever since her mastectomy and reconstructive surgery, her limited range of motion—that is, how far and in what directions someone can comfortably extend her arms, let's say, or turn her body easily—has bothered her. Nine years into survivorship, she says, she still hasn't recovered entirely. On a scale of 1 to 10, with 10 being the movement she had before her treatment began, she rated her ability to move easily and comfortably the first year after her surgeries at 3 or 4. Now, she says, it's closer to a 6 or 7. "Range of motion is still a problem," she notes.

What causes this? Tightness created by scar tissue after surgery, radiation, moving muscle and tissue during reconstructive surgery, or simply disuse can limit your range of motion. Tightness also can lead to poor posture, which may contribute to other problems like an aching back. Over time, careful stretching expands a limited range of motion and helps release tightness.

• Rebuild muscle and regain strength. Sarcopenia is a simultaneous loss of muscle and gain in fat tissue. Aging, inactivity, chemotherapy, menopause, and possibly other hormonal changes brought on by breast cancer treatments all may cause muscle to dwindle while fat tissue builds up. Typically, excess weight accumulates as well. Exercise helps pare off unwanted pounds and rebuild muscle. Tipping the fat-muscle ratio of your body more favorably in the direction of muscle helps reverse losses in muscle and gains in fat that frequently occur during chemotherapy. Fat cells release estrogen, which fuels some breast cancers, and excess weight is associated with higher mortality in women who have had breast cancer.

Moving muscles during reconstructive surgery—a latissimus dorsi flap, for example, uses a large back muscle to re-create the breast—affects strength. Your body is quite practical, however, and often can use other muscles to help compensate for those no longer in their original place. Strengthening the appropriate compensating muscles helps ensure that you will be able to perform simple tasks like closing the hatchback or trunk of a car or lifting heavy groceries and comfortably engage in enjoyable activities such as cross- country skiing or tennis. Strength training also addresses muscle imbalances, which affect posture in ways that can spell future pain.

• Keep bones healthy. Research suggests that chemotherapy may speed bone loss in premenopausal women. In a Harvard study detailed in Chapter 2, researchers have found that within one year after beginning chemotherapy, particularly if chemotherapy induces premature menopause, a woman can lose 7 percent of the bone mass from her spine and 4 percent from her hips. For a woman going through natural menopause, this amount of bone loss usually takes five years to occur. Weight-bearing exercise, such as walking and strength training, coupled with calcium and vitamin D supplements as well as bone-saving medication, when appropriate, helps preserve bone.

• Quell treatment-related nausea. Some research shows that exercise may lessen nausea during chemotherapy, which will certainly improve your quality of life.

• Enhance appearance. Often, changes stemming from treatment undermine appearance and self-esteem. A 40-year-old woman undergoing chemotherapy commonly experiences a 2.5 percent increase in body fat in one year. That's the equivalent of what typically occurs over 10 years to a 40-year-old without breast cancer. Exercise—which tones muscles and trims fat—helps turn back that clock.

• Net additional health benefits. Performed regularly, exercise tunes up the heart and lungs, eases insomnia and mild depression, boosts self-esteem, reduces high blood pressure and high cholesterol, and helps ward off many health conditions that shorten lives, including diabetes, colon cancer, heart disease, and stroke. On the other hand, being inactive is a risk factor for nearly all of these health concerns. When you realize that the majority of women who have had breast cancer will outlive their diagnosis and die one day of another cause entirely, it's easy to see how important staying active is for all of us.

Why Eat Well?

Eating well gives your body the energy and nutrients needed for healing, a process that continues after treatment ends. Protein, for example, is a building block used in the new cells that replace those lost to chemotherapy and radiation. Protein is necessary, too, during the cycles of regeneration and remodeling that take place in the skin after surgery. Countless other nutrients found in food play roles in healing as well. Vitamin C, vitamin A, zinc, and carbohydrates, fats, and fatty acids are a few examples.

Nutrients that help strengthen bones include calcium, vitamin D, vitamin K, magnesium, and phosphorus, which are found in food and available also through a daily multivitamin and supplements combining calcium and vitamin D. According to the National Osteoporosis Foundation, osteoporosis—a condition in which bone density thins out, leaving bones increasingly brittle and thus more likely to fracture—affects an estimated eight million women. As explained briefly in the preceding section as well as later in Chapter 2, research suggests the loss of bone mass that leads to osteoporosis may be hastened in women who experience menopause induced by chemotherapy. One study suggests chemotherapy may accelerate bone loss even when it does not prompt early menopause.

The foods you choose may have many other healthful nutrients. Filling much of your plate each day with a variety of colorful, pungent vegetables and fruits ensures you of a good supply of antioxidants, a catchall term for any compound that can counteract unstable molecules like free radicals, which are thought to have a hand in cancer, heart disease, and many other ailments. Paired with these antioxidants are countless other helpful nutrients that are not found in bottled supplements.

What about news reports that dietary fat may play a role in breast cancer recurrence? In 2005, researchers delving into this question through the large- scale Women's Intervention Nutrition Study (WINS) found that breast cancer recurred less frequently in those who consistently ate a low-fat diet. It is important to note that study participants who successfully stuck with the low- fat diet lost weight (roughly five pounds) and sustained this weight loss over the five years of the study. By contrast, during breast cancer treatment, most women gain weight. Many scientists speculate that it was the ability of WINS participants in the low-fat group to achieve and maintain a more healthy weight that led to fewer breast cancer relapses. Of course, a decrease in dietary fat and the substitution of fat calories with calories from fruits and vegetables may have played a role, too.

Currently, there is no other scientific evidence that even the healthiest diet will minimize the odds that breast cancer might recur. Possibly research will one day show this. Meantime, a varied diet that emphasizes vegetables, fruits, whole grains, beans and legumes, fish, poultry, and healthful oils (see Figure 1.1) does offer breast cancer survivors many important benefits by helping to ward off a variety of other cancers, diabetes, and cardiovascular ailments like heart attacks and strokes, among other illnesses.

What's more, loading up on vegetables and fruits can help crowd out less healthy foods—foods that often are higher in calories—simply because you'll be too full to eat them. That can help you reach or remain within a healthy weight range, which does appear to boost survival odds and lower recurrence rates among women who have had breast cancer. (See Chapter 2 for a full discussion of body mass index and healthy weight ranges.)

These tips can help you set yourself up to succeed:

• Make healthy foods available. Clear less healthy options out of your cabinets and refrigerator and restock regularly with healthy choices. Try to have quick, easy foods such as sliced vegetables on hand. Paying extra for shopping the salad bar or buying baby carrots may be worthwhile if you lack the time or energy to prepare foods.

• At the grocery store, read labels carefully and make trade-offs that net you fewer calories and healthier fats. Emphasizing foods that deliver relatively few calories per mouthful—romaine lettuce or carrots, for example, versus sirloin steak, cheese, or nuts—tends to fill you up faster at the table while cutting down calories, too.

• Eat mindfully. Truly taste your food and enjoy texture, scent, and visual pleasures rather than hurrying through a meal or nibbling while reading or watching TV. Slowing down as you eat helps in another way, too. The hormones in your gut that are responsible for signaling satiety—the news flash that announces that you've eaten enough—take about 20 minutes to deliver the message to your brain. Once that happens, you'll feel full.

• Don't confuse thirst for hunger. The thirst mechanism in humans is not well developed, and signals for both thirst and hunger originate in the same area in the brain, the hypothalamus. Often it is hydration our bodies crave, rather than calories. Keep on hand a glass of plain water, low-calorie flavored water, tea, or V8 juice. Phosphorous bubbles in carbonated beverages may leach calcium from the bones, so drink carbonated beverages in moderation.

• Tune in to emotional cravings that can trip off overeating and have a plan in place for moments when emotional hunger strikes. Turning to connections that make you feel happy, vital, and loved—whether family, friends, a partner, a pet, meditation, meaningful work, creative efforts, or enjoyable pursuits—may be an engaging substitute for unnecessary calories that affect your health as a breast cancer survivor. A quick walk or a few exercises often helps. A change in activities offers a distraction that can take your mind off food.

Why Rest?

The hours you spend sleeping appear to offer even more than a much-needed rest. While the links forged are still tentative, one sleep study that followed nearly 500 young adults for 13 years found that those who got the least sleep were apt to gain the most weight over time, although this association trailed off after age 34. Another much smaller study suggests insufficient sleep may tamper with levels of two appetite-regulating hormones: leptin, which suppresses hunger, and ghrelin, which enhances it. When sleep was deliberately curtailed, leptin levels dipped, ghrelin levels rose, and participants reported feeling hungry.

Burrowing beneath the covers for a sound night's sleep might have other benefits, too. Emerging evidence suggests that the hormone melatonin helps to spur production of certain immune cells and slow breast cancer cell growth. Nighttime darkness—for example, a bedroom with lights off and no flickering TV or glimmering streetlamp light—signals the pineal gland in the brain to churn out melatonin. Exposure to light during nighttime hours lessens the amount of melatonin released. Because some research suggests that the risk of developing breast cancer rises when melatonin levels are suppressed over the course of decades, it's worth speculating, as some experts do, that sleeping in a dark room every night may be one more way to reduce breast cancer risk. Support for this theory comes from the long-term Nurses' Health Study data published in 2006, which showed that nurses who routinely worked the night shift for 20 years or longer had a higher rate of breast cancer than those who worked during the day. Similar findings have occurred in other studies comparing female night-shift and day-shift workers and in research correlating morning melatonin levels to breast cancer risk.

One side effect of breast cancer treatments like surgery, chemotherapy, and radiation is that your body channels a great deal of energy into repairing or replacing damaged cells. Certain chemotherapy drugs temporarily suppress red blood cell production. Since red blood cells carry oxygen to cells throughout the body, this prompts anemia, which causes a fatigue that lifts gradually as the red blood cell count rebounds. Yet as treatment proceeds, exhaustion may snowball, especially if you have several types of treatment.

Not surprisingly, that can leave you feeling wiped out, as Dr. Kaelin found in the course of her own chemotherapy. "During my medical training—and particularly during my five-year surgical residency when I often was on call every other night—I became well accustomed to working through fatigue. Prior to being treated for breast cancer, six to seven hours of sleep left me well rested," she notes.

Yet while receiving chemotherapy and for months afterward, exhaustion prompted her to sleep nearly twice that long at night and sometimes nap during the day, too. "Even after sleeping deeply for 14 hours straight, I would wake up feeling fuzzyheaded, lethargic, and not refreshed. It took months before I started feeling like myself again."

Sometimes fatigue is tied to specific health issues, such as persistent anemia, medications, poor nutrition, depression, or a thyroid disorder called hypothyroidism. That's why it's important to tell your doctor about fatigue, especially if it is long-lasting. She or he can consider whether medications or a health problem might be the underlying cause.
(Continues...) Excerpted from The Breast Cancer Survivor's Fitness Plan by CAROLYN M. KAELIN. Copyright © 2007 by President and Fellows of Harvard College. Excerpted by permission of The McGraw-Hill Companies, Inc..
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The only breast cancer recovery program designed by a Harvard doctor and survivor and approved by the American Council on Exercise (ACE)

Feel healthy again. Regain control of your life.

Exciting new research reveals that regular exercise can reduce the chance of breast cancer recurrence and extend your life. Exercise can also help you recover energy, strength, and flexibility diminished by lifesaving breast cancer treatments.

Dr. Carolyn Kaelin is a leading breast cancer surgeon who understands the important links among exercise, recovery, and the quality of life—and she is a breast cancer survivor, too. Designed with master trainers Josie Gardner and Joy Prouty, The Breast Cancer Survivor's Fitness Plan features effective, inspiring workouts tailored for each type of surgery and adapted for differing fitness levels.

Feel strong again and

• Improve your flexibility and balance
• Rebuild your muscles
• Protect your bones
• Enhance your appearance, vitality, and all-around health

For more information on Dr. Kaelin about breast cancer treatment and recovery, read her award-winning book Living Through Breast Cancer.