Interview Spotlights

Interview Spotlights

Valuable insight from leading experts

Exercise regimen positively impacts all patients with breast cancer

Julie Gralow, MD

Julie Gralow, MD

Julie Gralow, MD, is director of breast medical oncology at Seattle Cancer Care Alliance, a member of the clinical research division at Fred Hutchinson Cancer Research Center and a professor in the medical oncology division at the University of Washington School of Medicine. She spoke with Healio about the benefits of regular exercise for patients with breast cancer and how clinicians can help encourage patients to begin, or continue, an exercise regimen following their diagnosis.

How does a regular exercise program influence outcomes for patients with breast cancer?

There’s been a lot of work done to understand the impact of physical activity and exercise in patients with breast cancer. If you start exercising before you are diagnosed, many epidemiologic studies clearly demonstrate that exercise reduces your risk for getting breast cancer in the first place. There’s no magical prevention strategy; many of my patients were exercising very actively before they were diagnosed. But it does reduce your risk – and that’s what’s important.

The reason I mention that, before we get into exercising after you’re diagnosed with breast cancer, is that most women with breast cancer still have breast tissue left, unless they choose to have both breasts removed with a bilateral mastectomy. Whatever the factors were that led those women to develop breast cancer in the first place, once they’re diagnosed, they have a higher risk for a second breast cancer unless all tissue in both breasts is removed. All this data on exercise reducing the incidence of breast cancer also demonstrate that exercise reduces the likelihood of a second, totally separate breast cancer, and that’s really important.

When we talk about the importance of exercise after you’ve been diagnosed, we have randomized studies, most of them small, in patients undergoing chemotherapy and radiation therapy and after surgery. Those randomized studies have consistently shown that, for example, surgical healing and range of motion is improved with exercise after surgery. Women who undergo radiation have reduced pain and a better overall quality of life, including improved mood and a decreased likelihood of depression. Women treated with chemotherapy experience the same kind of benefit, including less fatigue, less anxiety, less depression and better overall quality of life. While you’re on active treatment, there are clear benefits.

There are also population-based studies – not randomized studies – that looked at the correlation between exercise and recurrence and survival. These studies demonstrated that women who exercise after a diagnosis have fewer recurrences and are less likely to die from breast cancer. Exercise also helps patients tolerate the treatment better, which, in theory, might allow people to finish a complete course of treatment and without treatment delays. Also, in some large studies with longer follow-up like the Nurses’ Health Study, we saw fewer deaths and fewer breast cancer recurrences.

Does reducing anxiety, fatigue and, potentially, depression through exercising positively impact a patient’s ability to complete treatment?

Increasingly, we’re recommending longer durations of therapy, as long as 10 years for women on long-term endocrine therapy, and compliance – adherence to the medication – is critical to its success. Even in studies with motivated patients, 30% to 40% of participants don’t complete their full, intended course of adjuvant endocrine therapy. This happens for a lot of reasons, but some of it is due to the fact that, overall, the patient may just not feel well; some of it is due to joint aches. Exercise has the potential to treat both issues. Then, if you’re feeling better on these drugs, you’re going to be more likely to complete the intended course of therapy, which may also reduce the risk for recurrence and death.

How does the stage of disease and the stage of the treatment impact the types of exercise that you recommend?

The benefits for a person’s emotional well-being should be there irrespective of the disease stage. A person’s physical well-being benefits from exercise, too, though the benefits may be affected by the disease stage and the treatment regimen. Recurrence and survival benefits of exercise are certainly related to stage. However, I make exercise recommendations, tailored to the patient’s functional status, for patients with ductal carcinoma in situ, who have no risk of distant recurrence, and for patients with advanced, stage 3 disease, and even patients with metastatic disease.

We have a clinic for patients with DCIS and high-risk intra-epithelial lesions. One thing we try to do in this clinic is separate the risk of DCIS from invasive cancer in the patient’s mind as well as in the provider’s mind. I saw a patient at my DCIS clinic recently who was emotionally paralyzed by the diagnosis. I saw her for a second opinion a year after her diagnosis and she was still panicked about her risk for dying from breast cancer, even though she had DCIS with essentially no risk of distant recurrence. She felt that she had no sense of control over her diagnosis and long-term outcome. We talked about what she could control, such as a healthy lifestyle, including physical activity and maintaining a healthy body weight, which could help with the anxiety and the depression and the fear of recurrence. I recommended going for her follow-up mammograms and continuing tamoxifen to reduce her risk for another breast cancer. But those are more passive activities, to a degree. We’re doing things for and to her, as clinicians, but what she can really take control of is eating healthy, maintaining a good body weight, getting physical activity and not drinking alcohol in excess. That will help improve her overall health, including reducing her risk for heart disease and stroke. I do vary my exercise recommendations based on the patient – looking at their comorbidities, age and functional status, because they need to do something they can tolerate – but I don’t base it on stage.

How do you encourage patients who say they are not able to exercise because of fatigue, side effects from the treatment or other, similar issues?

Every patient is different, so you have to modify your recommendations from patient to patient. The American Board of Sports Medicine provides general guidelines for patients with cancer who are otherwise healthy. Those guidelines recommend what the CDC recommends for all American adults, which is 150 minutes of moderate-intensity aerobic activity per week, as well as some resistance strength training a couple times per week. That’s where we start from with our recommendations, then we try to scale it to the patient.

A lot of patients who have not exercised have physical limitations, but you can start gently. Yoga can be a good starting point in patients who have been physically inactive. It’s an exercise you can start gently.

On one occasion, I was with a group doing global work in Zambia. A breast cancer patient advocate from Seattle came with us. She’s an amazing woman who is a vital part of the program who knows that she should be exercising more. One of the members of the team was a yoga instructor who volunteered to lead an early sunrise yoga session for anybody who was interested. Everybody went, including the patient advocate. She is normally very excited for everything and is the most positive person, but, in this instance, she said, “I can’t do yoga.” The instructor said, “I’ll help tailor it to you.” The fascinating thing was that, with a good yoga instructor, she did find positions she was comfortable with and that she could hold. At the end of the session, she ran up to me and said, “I can do yoga!”

I say this to illustrate why I like to start with this particular exercise. It might be that even a patient who is physically challenged and thought she couldn’t do anything can do yoga with the right kind of guidance. Swimming is the right activity for a lot of my patients because they have joint problems and this is an activity that essentially takes the weight off your hips, your knees and your other joints. That may be a good approach, too.

Importantly, it has to be an activity that motivates you. I have a patient with stage 1 breast cancer who is 50 years of age and is receiving adjuvant endocrine therapy. She’s not overweight, though she is borderline, but she’s doing great. She asked me what she could do to decrease the risk for recurrence besides continuing endocrine therapy and undergoing regular mammograms. I asked what kind of exercise she was doing and she said none. This is a healthy 50-year-old woman; she and I had talked about the benefits of physical activity before, so I asked what was preventing her from exercising. She said some of it was time and some of it was motivation, so I asked her what she thought she could do, what would motivate her and what could even be fun for her. I referred her to our local Team Survivor Northwest program, an exercise and fitness support group for women with cancer. I also told her I’d be checking in again at our next visit.

You’ve discussed encouraging patients by exercising yourself. How does that fit into the conversation about exercise?

I do find that, occasionally, a patient will say, “You’re super busy, how do you do it?” and then I’ll discuss how I fit physical activity in. I let them know I believe in it; they also know that, if I can find the time to fit training into my life, then they probably should be able to as well.

Along with a colleague in sports medicine, we’re piloting a project called “exercise as a vital sign.” This approach suggests asking, when taking vital signs during a clinic visit, how many times the patient has exercised in the prior week and the average duration of each session.

We print that information out along with the other vital signs and it’s given to the clinician as they enter a room. It generates dialogue on the topic and lets the patient know we feel it’s important. Having the information in front of them encourages clinicians to comment on the answers.

In our pilot, one of our endpoints looks at weight loss (or lack of weight gain). We aim to create a dialogue and refer the patient to appropriate resources.

Disclosure: Gralow reports no relevant financial disclosures.