Study changes rules on breast-cancer care

Women treated for breast cancer are warned to avoid heavy lifting - including groceries, babies, and hefty handbags - for fear they'll develop chronic arm swelling.

A new study led by University of Pennsylvania researchers shatters this guidance. By lifting weights twice a week for a year, breast-cancer survivors with the swelling had fewer debilitating symptoms and flare-ups, even as they grew stronger.

In fact, some of the 70 iron-pumpers completely controlled the unsightly, incurable fluid buildup called lymphedema.

"It's just a wonderful program," said Jackie Amarnek, 77, of King of Prussia, who still works out regularly. "My arm looks perfectly normal now; you'd never know there's anything wrong."

The study, published in today's New England Journal of Medicine, is the largest and most rigorous to show clear-cut benefits - and no risks - to slow, progressive strength training for women with breast-cancer-related lymphedema.

The condition develops when fluid flowing through the channels of the lymph system backs up behind an obstruction. In breast-cancer patients, the problem stems from the removal of one or more small bean-shaped lymph nodes under the arm next to the diseased breast. The nodes are dissected to check for the spread of cancer.

Lymphedema is both unpredictable and common, affecting 20 to 30 percent of the nation's 2.4 million breast-cancer survivors. Amarnek, for example, developed swelling about a year after surgery; her mother, another breast-cancer survivor, never had the problem, despite having many more nodes removed.

The fluid accumulation, which can become disfiguring, is more than a cosmetic problem. The lymph system is part of the infection-fighting immune system, so disrupting it "changes the arm's ability to respond to injury or infection," said Kathryn Schmitz, the epidemiologist at Penn's Abramson Cancer Center who led the weight-lifting study.

"Inflammation such as sunburn can be a problem," Schmitz said. "Gardening becomes dangerous."

That's why cancer experts and breast-cancer support groups have long recommended that survivors avoid strenuous, repetitive arm movements that might cause injury. Those include lifting, scrubbing, pulling, and pushing.

But it's impractical for survivors to never lift toddlers or push a mop, wrote Wendy Demark-Wahnefried in an editorial accompanying the Penn study.

And what are women to do if the standard lymphedema treatments stop working?

Amarnek, for one, became depressed. A minor injury - she nicked a finger while closing an umbrella - turned her arm into a massive, weakened burden. She underwent months of lymph massage by a therapist, and wore a compression sleeve and glove during the day and mummylike bandages at night. Nothing helped.

"It really had me down," she recalled of her 2005 nadir. "Then, out of the blue, I got the letter from Penn."

Through advertisements and letters, Penn recruited 170 women with lymphedema. Half the women were given a year's free membership to a nearby YMCA or gym where fitness staff had been specially trained to coach them through upper- and lower-body weight-lifting workouts, as well as stretching exercises. The other half of the women did not work out, but were entitled to the same benefits after the study, conducted from October 2005 to March 2007.

Among the women who did not work out, 29 percent had lymphedema flare-ups, compared with 14 percent of the weight-lifters. The severity of symptoms such as pain, puffiness, tight jewelry, and difficulty writing or typing decreased 13 percent for weight-lifters, compared with 4 percent for the control group.

And while the control group had no increase in strength, the lifters added both upper- and lower-body power. Their average bench press went from 43 pounds to 53 pounds - a 23 percent increase.

Amarnek, who lifts 10-pound hand weights instead of barbells because of an old shoulder injury, now does 50 repetitions per arm, plus bicep curls and tricep pushdowns.

Not bad for a self-proclaimed klutz who got doctors' excuses to get out of high school gym.

"My husband says I'm getting too strong," she quipped, adding that getting fit has given her a new circle of friends.

"This was a life-altering event for many of the women," Schmitz said. "What we heard over and over was that it not only improved their quality of life, but changed how they perceived themselves. They felt more sexy and were willing to show their arms."

This is not the first study to show such benefits from defying conventional wisdom. In the mid-1990s, Donald McKenzie, a Canadian sports-medicine physician, showed that breast-cancer survivors developed strength, solidarity, and self-esteem while paddling dragon boats - a sport that is now internationally popular among survivors.

But many of those women did not have lymphedema.

The Penn study is the first large, well-designed study to focus on lymphedema sufferers, including many African American women and women from "a broad range of occupational and educational levels," noted Demark-Wahnefried of the M.D. Anderson Cancer Center in Houston.

She wrote that the weight-lifting program "clearly has the potential to result in cost savings, not only by reducing direct health care costs, but also by reducing . . . disability and allowing women to return to work at full capacity, either within or outside the home."

Toward that end, Schmitz and her colleagues are working to make weight-training a routine part of breast-cancer patients' recovery. They are collaborating with organizations including the Lance Armstrong Foundation, the national YMCA, the American College of Sports Medicine, and St. Joseph's University. In addition, the Abramson Cancer Center's Web site, www.penncancer.org, is compiling a list of local weight-training programs.

"There's a groundswell now," Schmitz said.

Lymphedema is the buildup of fluid in soft tissues when the lymph system is damaged or blocked. It usually affects an arm or a leg.

Causes include infection, injury, cancer, surgical removal of lymph nodes, or scarring from radiation treatment.

Symptoms include swelling,

a tight or heavy feeling, burning, and skin changes.

Treatment commonly includes massage therapy, tight bandages, and compression garments.

Preventive measures involve skin care, activity, and lifestyle. (Obesity increases the risk of lymphedema.) For more information, see the National Lymphedema Network at www.lymphnet.org.

SOURCES: National Cancer Institute, Abramson Cancer Center

of the University of Pennsylvania

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