Our Study Shows that Toronto Rehabilitation Institute’s ‘HEALTh’ Breast Cancer Exercise Program Works

I was recently involved in an evaluation of the Toronto Rehabilitation Institute’s Health, Exercise, Active Living, and Therapeutic Lifestyle (HEALTh) program for breast cancer survivors (ref 1). This breast cancer exercise program consists of weekly supervised exercise sessions combined with educational seminars, with an aim to help women recover from the physical and psychological side-effects of breast cancer and its treatment.

Results of our study were just published in the Journal of Cardiopulmonary Rehabilitation and Prevention (you can find the abstract here). At first blush this might seem like an odd journal to publish cancer rehabilitation research in, but not in this case.

Despite the well documented benefits of exercise for cancer survivors, there remains a lack of pragmatic information describing how a breast cancer exercise program should be implemented.

In other words, there is no established standard of care for breast cancer exercise programs (or for any other cancer for that matter). For this reason, the Toronto Rehabilitation Institute’s (TRI) HEALTh program was designed using their existing Cardiovascular Prevention and Rehabilitation Program as a model and is held in the same facility, as a specialized substream of this existing cardiovascular program.

Cardiovascular rehabilitation programs have enjoyed a long history of success for patients with cardiac disease, and established program frameworks have been published (ref 2). As with cancer rehabilitation, the goal of cardiovascular rehabilitation is to improve both physical and psychological fitness, and a central challenge is finding ways to get patients engaged and motivated to make exercise a part of their lives in a meaningful way.

Existing cardiovascular rehabilitation programs (such as the one offered by TRI) are a valuable starting point for establishing an effective cancer rehabilitation program.

In this article, I will discuss why joining a breast cancer exercise program such as TRI’s HEALTh program is particularly valuable, and highlight the benefits that we observed for patients enrolled in it.

Why join TRI’s HEALTh cancer exercise program, or any other program?

Common side-effects of cancer treatment can be treated through exercise

Although cancer treatment is obviously beneficial for extending life, this does not come without a cost. Cancer treatments including surgery, radiation and chemotherapy cause both short-term (acute) and long-term (chronic) complications, some of which are associated with decreased quality of life.

Side-effects of breast cancer treatment that have been shown to benefit from exercise therapy:

1. Physical deconditioning (reduced cardiovascular fitness, strength, endurance) and weight gain
2. Fatigue
3. Pain
4. Depression
5. Breast cancer-related lymphedema
6. Quality of life (which is influenced by a variety of factors including the above)

Guidelines generally recommend 150 minutes per week of aerobic or resistance exercise. Not surprisingly, evidence suggests that this can help reduce and reverse physical and psychological deconditioning, and can also help prevent deconditioning if implemented during therapy (ref. 3).

Better still, physical activity is associated with a decrease in cancer recurrence and overall mortality.

The beneficial effect of fitness on breast cancer survival appears to be dose-dependent, meaning that the more fit you are the better your survival rate. Further to this, it can also help prevent new incidence of breast cancer.

Clearly there are lots of great reasons for breast cancer (and all cancer) survivors to engage in an exercise program, and to stick with it.

Sticking to an exercise program can be unusually difficult for survivors

Starting and sticking with an exercise program can be hard at the best of times, but even more difficult for patients actively undergoing cancer treatment, or recovering from it. Studies show that regular physical activity is much less common in patients who have had a cancer diagnosis.

More challenging still, cancer survivors are likely to start out at a fitness deficit following treatment. Research shows that breast cancer patients display reduced cardiorespiratory fitness both during and after chemotherapy, which appears to be caused by biological changes that inhibit normal oxygen delivery systems in the body (for example, ref. 4). These effects can persist for years (ref. 5). Radiation and chemotherapy can also reduce cardiorespiratory fitness by damaging lung function (for example, ref. 6).

These issues may contribute to the increased risk of cardiovascular disease that has been observed in breast cancer survivors.

Therefore, to be successful, breast cancer exercise rehabilitation programs need to be more than just a cardio or resistance training routine. They need to acknowledge and address the physical and psychological barriers to exercise that are unique to each patient.

TRI’s HEALTh program is designed to maximize the benefits of a breast cancer exercise program – and help you stick with it.

Exercise is commonly recommended as a means of reducing the treatment related side-effects of cancer therapy, but information is sparse on how to implement this recommendation in the real world. Critical to this is overcoming the hurdles of patient adherence, and the psychosocial barriers to exercise.

Based on the success of the cardiovascular rehabilitation program, the breast cancer HEALTh program employs a three-pronged strategy to promote meaningful and long-lasting cancer rehabilitation:

1. A combination of aerobic (“cardio”) and resistance training is prescribed to each patient individually, based on a thorough assessment of their needs and adjusted for any limitations imposed by their particular cancer / cancer treatment.
2. Educational seminars are included in the program to educate participants on exercise and cancer; breast cancer-related lymphedema; exercising in hot and cold weather; exercise and cardiovascular disease; overtraining and undertraining; goal setting and symptom management; nutrition; stress management; and relaxation and meditation.
3. Peer mentorship and support is encouraged through a staggered group enrollment design, where patients are enrolled in groups of 15 every 3 months.

This program is delivered in 22 weekly supervised sessions, with activities prescribed to be performed at home as well (up to 2 resistance and 4 cardio activities per week).  Twelve additional sessions are offered at the rehab facility which include further education, goal setting, and peer support.  The overall goal is to encourage 5 exercise sessions weekly.

What are the demonstrated benefits of TRI’s HEALTh cancer exercise program?

Our study, conceived and led by Dr. Lianne Dolan, analyzed the data from 152 patients enrolled in the TRI HEALTh program between 2010 and 2014.

Measures of cardiorespiratory fitness and quality-of-life (including depression) at the time of admission into the HEALTh program were found to be below published averages for healthy women of the same age (‘age-matched’).  This was to be expected based on our understanding of breast cancer treatment side-effects.

Two-thirds of enrolled participants adhered well to the exercise program (the remainder withdrew for medical and nonmedical reasons), and the results were improved cardiorespiratory fitness (14% improvement in VO2 peak versus baseline), improved quality of life (by a meaningful amount), and reduced depression scores.

Although improvements in cardiovascular fitness were significant and meaningful, these participants did not reach normal published values for fitness levels by the end of the program. This suggests that participants should continue exercising beyond the end of the program, ideally making it an ongoing part of their lifestyle. This result also lends support to the recommendation to initiate exercise therapy during cancer treatment.

Contrary to other published reports, pain wasn’t shown to improve in this study. This may be a result of the measures that were used to quantify pain, and/or it may indicate that supplementary physiotherapy may have been needed to address specific sources of pain (for example: scar tissue, axillary web syndrome, neuropathic side-effects, or other musculoskeletal side-effects of cancer treatment).

Participants were also found to achieve a small but significant reduction in body weight, and as expected, exercise did not provoke breast cancer-related lymphedema.

Summary

While this study suffered from limitations, such as that fact that it was a single-centre retrospective analysis (rather than a multi-site controlled experiment), its findings lend support to existing breast cancer exercise research and recommendations. Importantly, it also offers a practical framework for creating effective breast cancer exercise rehabilitation programs – based on an existing cardiac rehabilitation model.

The best evidence says that physical and psychological deconditioning are significant side-effects of cancer treatment, but that these can be treated through exercise.

Toronto Rehabilitation Institute’s HEALTh program offers what appears to be an effective three-pronged strategy to help overcome the unique barriers to fitness experienced by a breast cancer population, and achieves meaningful health outcomes.

References

1. Dolan, L.B., Barry D., Petrella T., Davey L., Minnes A., Yantzi A., Marzolini S., Oh P. The Cardiac Rehabilitation Model Improves Fitness, Quality of Life, and Depression in Breast Cancer Survivors. J Cardiopulm Rehabil Prev. 2017 May 18 [Epub ahead of print].
2. Balady GJ, Williams MA, Ades PA, et al. Core components of car­diac rehabilitation/secondary prevention programs: 2007 update: a scientific statement from the American Heart Association Exercise, Cardiac Rehabilitation, and Prevention Committee, the Council on Clinical Cardiology; the Councils on Cardiovascular Nursing, Ep­idemiology and Prevention, and Nutrition, Physical Activity, and Metabolism; and the American Association of Cardiovascular and Pulmonary Rehabilitation. Circulation. 2007;115(20):2675.
3. McNeely M.L., Campbell K.L., Rowe B.H., Klassen T.P., Mackey J.R., Courneya K.S. Effects of exercise on breast cancer patients and sur­vivors: a systematic review and meta-analysis. Can Med Assoc J. 2006;175(1):34-41.
4. Klassen O., Schmidt M.E., Scharhag-Rosenberger F., Sorkin M., Ulrich C.M., Schneeweiss A.., Potthoff K., Steindorf K., Wiskemann J. Cardiorespiratory fitness in breast cancer patients undergoing adjuvant therapy. Acta Oncol. 2014 Oct;53(10):1356.
5. Lakoski S.G., Barlow C.E., Koelwyn G.J., Hornsby W.E., Hernandez J., Defina L.F., Radford N.B., Thomas S.M., Herndon J.E., Peppercorn J., Douglas P.S., Jones L.W. The influence of adjuvant therapy on cardiorespiratory fitness in early-stage breast cancer seven years after diagnosis: the Cooper Center Longitudinal Study. Breast Cancer Res Treat. 2013 Apr;138(3):909.
6. Abid S.H., Malhotra V., Perry M.C. Radiation-induced and che­motherapy-induced pulmonary injury. Curr Opin Oncol. 2001;13(4):242.